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DISEASES    OF    THE    GALL-BLADDER 
AND  BILE-DUCTS 


OF 


THE    GALL-BLADDER    AND 
BILE-DUCTS, 

INCLUDING  GALL-STONES 


BY 

A.  W.   MAYO  ROBSON,  F.R.C.S. 

HUNTERIAN    PROFESSOR    OF    SURGERY   AND    PATHOLOGY,    1897,    1899,    AND    1903  ',    AND    VICE- 
PRESIDENT,    ROYAI.    COLLEGE    OF    SURGEONS    OF    ENGLAND,    I902 

ASSISTED    BY 

J.  F.  DOBSON,   M.S.  (Lond.),  F.R.C.S. 

LATELY      RESIDENT     SURGEON     TO      THE     GENERAL     INFIRMARY      AT      LEEDS 


THIRD    EDITION 


NEW    YORK 

WILLIAM     W  O  O  D     &     COMPANY 

MDCCCCIV 


PREFACE    TO    THIRD    EDITION 


Since  the  issue  of  the  second  edition,  so  much  progress 
has  occurred  in  the  pathology  of  the  diseases  of  the  gall- 
bladder and  bile-ducts,  and  such  improvements  in  the 
technique  of  the  various  operations,  that  the  whole  book 
has  had  to  be  recast. 

This  edition  is  therefore  not  merely  a  reproduction  of  the 
last,  but  almost  a  new  work. 

Besides  an  entirely  revised  chapter  on  the  Operative 
Technique  of  Gall-stones,  it  will  be  found  that  several  new 
chapters  have  been  added,  many  additional  cases  furnished, 
and  the  whole  of  the  work  has  been  brought  up  to  date. 

In  an  appendix  at  the  end  of  the  volume  will  be  found 
a  more  or  less  brief  account  of  all  the  operations  I  have 
performed  on  the  gall-bladder  and  bile-ducts,  539  in  number, 
and  an  analysis  will  show  how  much  more  serious  have  been 
the  later  series  of  cases. 

The  large  number  of  choledochotomies  for  stones  in  the 
common  duct  and  of  operations  for  pancreatic  disease  will 
at  once  attract  notice. 

Where  so  many  different  conditions  have  to  be  taken  into 
consideration  it  is  difficult  to  give  a  satisfactory  classification 
of  the  cases  operated  on,  but  I  hope  the  following  account 
of  the  principal  operations  will  give  some  idea  of  the  results 
that  have  been  obtained. 

Where  the  operation  of  cholecystotomy  has  been  under- 
taken for  simple  diseases,  such  as  gall-stones,  in  the  absence 
of  cancer  and  jaundice  with  suppurative  or  infective  cholan- 
gitis, the  mortality  has  onlv  been  1*06  per  cent. 

[v] 


vi  PREFACE  TO  THIRD  EDITION 

If  the  complicated  cases,  such  as  phlegmonous  cholecystitis, 
gangrene  of  the  gall-bladder,  suppurative  and  infective  cho- 
langitis (all  of  which  are  classified  by  Kehr  as  complicated 
cases)  be  included,  the  mortality  has  been  27  per  cent. 

If  the  cases  where  cholecystotomy  has  been  performed  in 
the  presence  of  cancer  of  the  pancreas  or  bile  -  ducts  be 
included,  the  mortality  of  the  whole  series  has  been  5*8  per 
cent. 

Where  cholecystectomy  has  been  performed  for  diseases 
other  than  malignant,  the  mortality  has  been  6*2  per  cent. ; 
but  where  the  cancer  cases  are  included,  it  has  been  14*3  per 
cent. 

The  operation  of  choledochotomy  for  removal  of  gall- 
stones from  the  common  duct,  which  up  to  July,  1901, 
showed  a  mortality  of  l6'2  per  cent.,  has  since  that  date, 
under  the  more  complete  exposure  which  can  now  be  obtained, 
shown  a  mortality  of  only  rg  per  cent.  ;  and  I  have  done  a 
consecutive  series  of  over  fifty  cases  of  choledochotomy  and 
duodeno-choledochotomy  without  a  death. 

Cholecystenterostomy,  in  simple  as  distinguished  from 
malignant  diseases,  has  given  a  mortality  of  5*5  per  cent., 
but  when  performed  for  cancer  of  the  pancreas  or  other  forms 
of  malignant  growth  the  mortality  has  been  so  considerable 
— six  out  of  eight  cases — as  to  lead  me  to  discontinue  the 
operation  where  cancer  can  be  positively  diagnosed. 

Cases  of  perforation  of  the  bile-ducts,  of  intestinal  obstruc- 
tion caused  by  gall-stones,  of  hydatid  disease  setting  up 
cholangitis,  and  of  disabling  adhesions,  will  be  found  in  the 
appendix,  where  also  will  be  found  accounts  of  exploratory 
and  other  operations,  which  I  hope  may  prove  of  interest  to 
those  engaged  in  the  treatment  of  similar  cases. 

I  have  to  thank  Mr.  J.  F.  Dobson  for  his  assistance  in 
looking  through  the  notes  of  my  cases,  as  well  as  for  his  help 
in  the  additions  that  have  been  made  to  the  text. 


A.  W.  MAYO    ROBSON. 


-    Park  '  Crescent,  i  W. , 

/  '     I  n.r,  1  ,    [903. 


PREFACE    TO    SECOND    EDITION 

Although  the  first  issue  of  my  lectures  on  '  Diseases  of  the 
Gall-bladder  and  Bile-ducts '  was  taken  up  within  a  few 
weeks,  want  of  leisure  prevented  me  from  preparing  a 
second  edition,  since  it  involved  a  recasting  of  the  whole 
book,  and  changing  it  from  the  lecture  to  the  narrative 
form. 

Had  it  not  been  for  the  kind  help  of  my  friend  Dr. 
Macrae,  who  has  assisted  me  in  my  operative  work 
during  the  past  two  years,  the  issue  must  have  been 
further  delayed. 

It  will  be  found  that,  besides  new  chapters  on  Membranous 
Cholecystitis  and  on  Gall-stones,  and  an  index,  many  addi- 
tions have  been  made  to  the  text,  and  that  my  further  opera- 
tive experience,  amounting  to  135  cases,  making  in  all  305 
operations,  has  been  included. 

Instead  of  arranging  the  cases  at  the  end  of  the  volume, 
they  have  been  classified,  and  placed  at  the  end  of  the 
sections  referring  to  the  operations  under  consideration 
(the  numbers  preceding  the  cases  having  reference  to  the 
order  of  operation),  which  has  seemed  to  me  and  my  co- 
editor  a  more  convenient  method  than  the  one  pursued  in 
the  first  edition. 

An  analysis  of  the  operations  will  show  that  far  more 
serious  cases  have  been  operated  on  in  the  later  series.    This 

[   vii    ] 


viii  PREFACE  TO  SECOND  EDITION 

is  especially  shown  in  the  operation  for  gall-stones  impacted 
in  the  common  duct,  as  well  as  in  the  cholecystotomies. 
In  the  latter  list,  it  will  be  found  that  the  mortality  in  chole- 
cystotomy  for  gall-stones  uncomplicated  with  deep  jaundice, 
infective  cholangitis,  or  cancer,  is  ri  per  cent.,  while  even 
including  the  malignant  cases  it  is  only  476  per  cent. 

I  would  take  this  opportunity  of  thanking  my  House 
Surgeon,  Mr.  J.  Williamson,  for  the  two  additional  drawings 
on  pp.  147  and  148. 

A.  W.  M.  R. 
7,  Park  Square,  Leeds, 
February,  1900. 


PREFACE    TO    FIRST    EDITION 


The  present  volume  is  a  reproduction  of  the  lectures  which, 
as  Hunterian  Professor,  I  had  the  honour  of  delivering  at  the 
Royal  College  of  Surgeons  of  England  in  1897.  The  views 
enunciated  are  the  results  of  many  years  of  observation  on 
a  class  of  cases  to  which  until  lately  too  little  attention  had 
been  paid. 

Thanks  to  my  medical  colleagues  on  the  staff  of  the 
General  Infirmary  at  Leeds,  and  to  my  many  medical 
friends,  I  have  had  the  opportunity  of  seeing  a  very  con- 
siderable number  of  cases  of  the  diseases  in  question,  and  of 
operating  on  those  where  surgical  interference  was  required. 
Perhaps  not  the  least  useful  part  of  the  work  is  the  synopsis 
of  a  consecutive  series  of  operations  performed  on  the  gall- 
bladder and  bile-ducts,  which,  for  convenience  of  reference, 
I  have  had  placed  in  a  tabulated  form  at  the  end  of  the 
volume. 

I  am  fortunately  able  to  state  that  I  have  never  lost  a 
single  patient  after  any  operation  for  gall-stones  in  the 
absence  of  malignant  disease,  deep  jaundice,  or  infective 
cholangitis,  and  it  will  be  found,  on  reference  to  the  list,  that 
cholecystotomy  for  gall-stones,  even  including  the  infective 
cholangitis  and  deeply-jaundiced  cases,  only  shows  a  mortality 
of  xmy  p#er  cent. 

I  feel,  therefore,  in  advancing  the  proposition  '  that  as 
soon  as  gall-stones  give  serious  trouble  their  removal  by 
operation  is  the  most  rational  method  of  treatment,'  it  is 
one  that  can  be  safely  supported,  since  it  is  only  from  the 
complications,  which  in  many  cases  of  cholelithiasis  arise 

[ix] 


x  PREFACE  TO  FIRST  EDITION 

sooner  or  later,  that  any  danger  after  operation  need  lie 
apprehended. 

I  mu?t  not  fail  to  thank  most  sincerely  the  pathological 
curators  of  the  Hnnterian  and  of  the  various  London  Medical 
School  Museums  for  their  unfailing  courtesy  and  kindness 
in  giving  me  every  facility  for  the  study  of  the  valuable 
specimens  under  their  care,  and  the  pathological  committees 
of  the  various  schools  for  their  kindness  in  allowing  me  to 
show  the  original  specimens  at  the  college  on  the  occasion 
of  my  lectures,  and  to  have  them  photographed  to  illustrate 
the  present  volume. 

My  thanks  are  due  to  my  friend  and  late  assistant,  Dr.  H. 
Colligan  Donald,  for  making  a  synopsis  of  and  arranging  my 
cases  ;  to  Dr.  F.  Gairdner  and  Dr.  Morton,  for  their  assist- 
ance with  the  diagrams  ;  to  Mr.  Godart,  for  the  excellent 
photographs  of  the  specimens  ;  and  last,  though  not  least,  to 
my  most  obliging  publisher,  Mr.  A.  A.  Tindall,  for  his  courtesy 
and  help  in  illustrating  and  in  publishing  the  work. 


A.  W.  M.  R. 


7,  Park  Square,  Leeds, 
June,  1897. 


CONTENTS 

CHAPTER  ['AGE 

I.    ANATOMICAL    CONSIDERATIONS  I 

II.    PHYSIOLOGICAL    CONSIDERATIONS    -                  -                  -  1 8 
OBSERVATIONS     ON     THE     SECRETION     OF     BILE    IN     A 

CASE    OF    BILIARY    FISTULA                   -                   -                   -  21 

DIURNAL    EXCRETION    OF    BILE               -                  -                  '  25 

CONCLUSIONS                  -                  -                  -                  -  29 
MR.    FAIRLEY'S    ANALYSIS         -                  -                  -                  "3° 

III.  INJURIES    TO    THE    BILE    PASSAGES-                  -                  -                  -  48 

IV.  INFLAMMATORY    AFFECTIONS                -                   -                   -  56 

CATARRH    OF    THE    GALL-BLADDER    AND    BILE-DUCTS    -  56 

OBLITERATIVE    CHOLECYSTITIS    AND    CHOLANGITIS         -  66 
CROUPOUS     INFLAMMATION      OF      THE     GALL-BLADDER 

AND    BILE-DUCTS  -  -  -  "75 

SUPPURATIVE  INFLAMMATION  OF  THE    BILE   PASSAGES, 

AND    ITS    RELATION    TO    MICRO-ORGANISMS               -  80 
SUPPURATIVE     INFLAMMATION     OF    THE     BILE     PAS- 
SAGES      -                  -                  -                  -                  -                 -  80 

simple  empyema  -             -             -             -  85 

acute  phlegmonous  cholecystitis  and  gangrene 

of  the  gall-bladder              -            -            -  89 

Infective  cholangitis         -             -             -             -  97 

suppurative  cholangitis    -             -             -             -  ioo 

ulceration    of    the    gall-bladder    and    bile- 
DUCTS     -                -                -                -                -                -  ioS 

STRICTURE    OF    THE    GALL-BLADDER    AND    BILE-DUCTS  112 

[   xi   ] 


xii  CONTENTS 

CHAPTER  PAGE 

IV.    INFLAMMATORY    AFFECTIONS    {continued) 

PERFORATION      OF      THE     GALL-BLADDER      AND      BILE- 
DUCTS     -                   -                   .                   -                  -  -  Il8 
FISTULA    OF    THE    GALL-BLADDER    AND    BILE-DUCTS  -  13I 
KINKING    OF    THE    BILE-DUCTS                 -                   -  -  1 39 
V.    INTESTINAL    OBSTRUCTION                   -                 -                  -  -  1 42 
VI.    TUMOURS    OF    THE    GALL-BLADDER    AND    BILE-DUCTS  -  1 66 
I.    TUMOURS    OF    THE    GALL-BLADDER                   -  -  1 67 
II.    TUMOURS    OF    THE    BILE-DUCTS        -                   -  -  1 95 

VII.  GALL-STONES,  OR    CHOLELITHIASIS                   -                  -  -  215 

DIAGNOSTIC    OPERATIONS           -               *-                 -  -  244 
GENERAL    CONSIDERATIONS    BEARING    ON    OPERATIONS 

ON    THE    GALL-BLADDER    AND    BILE-DUCTS  -  245 

PREPARATION    FOR    OPERATION                -  -  246 

VIII.  CHOLECYSTOTOMY                   -                 -                 -                  -  -  270 
IX.    CALCULI    IN    THE    COMMON    BILE-DUCT        -  -  278 

X.    CHOLELITHOTRITV                  -  -  285 

XL    CHOLEDOCHOTOMY  -----  288 

DUODENO-CHOLEDOCHOTOMV                                      -  -  295 

XII.    CHOLECYSTECTOMY                -                   -                   -                   -  -  298 

XIII.    CHOLECYSTENTEROSTOMY  -  305 

APPENDIX                                     -                                                      -  -  32  1 


LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

1.  GALL-BLADDER    AND    BILE-DUCTS  -  -  -  -2 

2.  DIAGRAM  SHOWING  RELATION  OF  GALL-BLADDER  TO  SURFACE  3 

3.  DIAGRAM    TO     SHOW    CONVOLUTED     APPEARANCE    OF     CYSTIC 

DUCT  -  -  -  -  -  -  -  7 

4.  DIAGRAM    OF    COMMON    BILE-DUCT      -  -  -         8 

5.  SECTION    OF    THE   FREE   BORDER   OF    THE    LESSER    OMENTUM, 

SHOWING  THE  RELATIONS  OF  THE  COMMON  BILE-DUCT        -         9 

6.  DIAGRAM    TO     SHOW    THE     AMPULLA     OF    VATER     WITH     THE 

ORDINARY     TERMINATION     OF     THE     COMMON     BILE-DUCT 
AND    THE    DUCT    OF    WIRSUNG         -  -  -  -       IO 

7.  8,  AND  9.     THREE    OTHER    TYPES    OF    TERMINATION     OF    THE 

COMMON    BILE-DUCT 

10.  BIFID    GALL-BLADDER    FROM    A    SHEEP 

11.  MELANOTIC     TUMOUR     OF     GALL-BLADDER     AND     GLAI 

PORTAL    FISSURE 

12.  LINGUIFORM    PROCESS    OF    LIVER 

13.  LINGUIFORM    PROCESS    OF    LIVER 

14.  CHART    SHOWING    DIURNAL    BILE    FLOW 

15.  CHART    SHOWING    DIURNAL    BILE    FLOW 

16.  CHART    SHOWING    DIURNAL    BILE    FLOW 

17.  LACERATION    OF    GALL-BLADDER 

18.  RUPTURE    OF    GALL-BLADDER 

19.  GALL-BLADDER    WOUNDED    BY    PITCHFORK      - 

20.  LACERATION    OF    GALL-BLADDER    FRCM    KICK 

21.  CHRONIC     CATARRH     WITH     DILATATION     OF     BILE-DUCTS     IN 

LIVER.       CANCER    OF    COMMON    BILE-DUCT  -        To  face  60 

2  2.    CONGENITAL    OBLITERATION    OF    BILE-DUCTS  -  ,,  68 

L  *"i  ] 


- 

12 

- 

14 

DS     IN 

To  fact 

•  '4 

- 

16 

- 

16 

- 

24 

- 

26 

- 

27 

To  J  ace 

48 

;. 

48 

11 

48 

>» 

48 

xiv  LIST  OF  ILLUSTRATIONS 

FIG.  PACiE 

23.  CONGENITAL     OBLITERATION     OF     BILE-DUCTS     (MICROSCOPIC 

SECTION)  -  -  -  -  -  -      70 

24.  CONGENITAL    ABSENCE    OF    THE    GALL-BLADDKR  -       To  face  74 

25.  OBLITERATION   OF   GALL-BLADDER    AND    COMMON    DUCT,  THE 

RESULT    OF    GALL-STONE    IRRITATION         -  -       To  face  74 

26.  HYDATID,     ROLLED   UP    AND    BLOCKING     COMMON    BILE-DUCT, 

PORTION    PROJECTING    INTO    DUODENUM  -     To  face  102 

27.  INFECTIVE   CHOLANGITIS,  SHOWING    DILATED    INTRA-HEPATIC 

ducts    ------   To  face  102 

28.  INFLAMMATION     OF      GALL-BLADDER     AND     BILE-DUCTS      IN 

typhoid  .....   To  face  104 

29.  ADHESION     OF     GALL-BLADDER     TO     STOMACH,    LEADING     TO 

DILATATION  OF  STOMACH  AND  SPASMODIC  PAIN      -    To  face   108 

30.  TYPHOID    ULCERATION    OF    GALL-BLADDER      -  ,,         I  I  2 

31.  PERFORATING  EPITHELIOMATOUS  ULCER  OF  GALL-BLADDER 

To  face  112 

32.  CANCER  OF  GALL-BLADDER  ULCERATING  INTO  COLON  ,,         112 
^    STRICTURE    OF    COMMON    BILE-DUCT                    -                   -  ,,112 

34.  ADVENTITIOUS      SAC      CONTAINING      GALL-STONE      SITUATED 

BETWEEN    HEPATIC    AND    CYSTIC    DUCTS  -     To  face  122 

35.  GALLSTONE    IN    ACT   OF    EXTRUSION    INTO    DUODENUM,    THE 

EDGES  OF  THE  OPENING  BEING  ULCERATED  -    To  face  1  38 

36.  A    PORTION    OF    LIVER  WITH  GALL-BLADDER  AND    A    PIECE    OF 

THE  TRANSVERSE  COLON  -  -  -    To  face   I  38 

37.  LARGE      GALL-STONE      PRODUCING      ACUTE      INTESTINAL      OB- 

STRUCTION     SUCCESSFULLY      REMOVED       BY      ABDOMINAL 
section  .....   To  face  149 

38.  GALL-STONES    PRODUCING    FATAL   OBSTRUCTION  -  ,,        152 
38a.    GALL-STONES    PRODUCING    FATAL   OBSTRUCTION        -           .,         152 

39.  LARGE     GALL-STONE      PRODUCING      VCUTE     INTESTINAJ      OB 

I'CTION     PASSED      PER      \Nl'\l,     WITH      RECOVERY     01 
I'M  II.--  1  -  -  -  -  -    To  fut'  152 

40.  LARGE   GALL-STONE    IMPACTED    IN    ILEUM,    AND    PRODUCING 

FATAL    OBSTRUl   HON  -  -    To  fact   152 


LIST  OF  ILLUSTRATIONS  xv 

Fig.  tag  p. 

41.  DRAWING    OF    GALL-STONE,  ACTUAL    SIZE,   FROM    CASE    30        -    1 58 

42.  GALL-STONE     IN     LUMEN    OF     BOWEL    BETWEEN     TWO    STRIC- 

TURES   DUE    TO    CHRONIC    TUBERCULOSIS  -    To  face  1 62 

43.  LARGE  SINGLE  CALCULUS  FILLING  THE  GALL-BLADDER  ,,        168 

44.  CALCIFICATION    OF    GALL-BLADDER     -  -  „         168 

45.  DISTENDED    GALL-BLADDER   AND   POUCH   AT    FUNDUS  CAUSED 

BV  CALCULUS  OBSTRUCTING  CYSTIC  DUCT  -    Tc  face  1 69 

46.  HYPERTROPHY     AND    DILATATION     OF    GALL-BLADDER,    WITH 

POUCHES    FORMED    BY    THE   MUCOUS    MEMBRANE    BULGING 
BETWEEN    THE    MUSCULAR    FASCICULI         -  -    To  face  1 69 

47.  CONTRACTED   GALL-BLADDER,  WITH  HYPERTROPHY  OF  WALLS 

DUE  TO  GALL-STONE  IRRITATION                     -  -  To  face  1 69 

48.  MICROSCOPIC    SECTION    OF    THE    NEW    GROWTH  -  ,,         180 

49.  CARCINOMA    OF    GALL-BLADDER            -                  -  -  ,,         180 

50.  CANCER    OF    GALL-BLADDER    INVADING    LIVER  -  ,,          1 80 

51.  EXCISION    OF    A   PORTION    OF    LIVER    FOR    TUMOUR  -       1 86 

52.  PAPILLOMATA    OF    THE    GALL-BLADDER  -  -    To  face  193 

53.  GROWTH  OF  GALL-BLADDER  :    CUT  SURFACE  OF  BASE  -  „         193 

54.  DILATED     COMMON     BILE-DUCT      FORMING     A     THICK-WALLED 

CYST    SIX    INCHES    IN    DIAMETER  -  -    To  face  2  00 

55.  CYSTS  IN  LIVER  FORMED  BY  DILATED  HEPATIC  DUCTS  ,,         200 

56.  TUMOUR     OCCUPYING     THE     JUNCTION    OF    HEPATIC,    CYSTIC, 

AND      COMMON     DUCTS,      AND     COMPLETELY      OCCLUDING 

them      ------    To  face  205 

57.  CANCER    OF    AMPULLA  -  -  -  ,,         205 

58.  ONE  HUNDRED  AND    FORTY-FIVE    GALL-STONES,  ACTUAL  SIZE, 

REMOVED    BY    CHOLECYSTOTOMY 

59.  EXAMPLES    OF    GALL-STONES 

60.  LARGEST   GALL-STONE    EVER    DESCRIBED 

61.  GALL-S TONES    IN    SITU    (SKIAGRAM)   - 

62.  VARIOUS    TYPES    OF    GALL-STONES    (SKIAGRAM) 

63.  SKIAGRAM    OF    GALL-STONES 

64.  GALL-STONE    SCOOP 

65.  DIAGRAM    TO    SHOW    INCISION 


To  face 

215 

>j 

215 

j) 

215 

■>•> 

236 

>» 

236 

>» 

236 

- 

247 

- 

264 

xvi  LIST  OF  ILLUSTRATIONS 

f  Hj  PAGE 

66.    DIAGRAM    TO    ILLUSTRATE    THE    FIRST    SUTURES   IN    CHOLE- 

DOCHOTOMV  -  -  -  -  "  -       290 

(.7.     HALSTEAD'S    MINIATURE     HAMMER,    FOR    USE   IN   SUTURING 

THE    1:11  B-DUI   l  -  291 

6S.  TRANSVERSE  SECTION  THROUGH  CENTRE  OF  POUCH  DE- 
SCRIBED ------       292 

69.  DIAGRAM   TO   SHOW  APPLICATION    OF   MUCOUS  OR  MARGINAL 

SUTURE    IN    THE    BONE    BOBBIN    OPERATION  -  -       307 

70.  DIAGRAM     TO    SHOW    APPLICATION    OF    SEROUS    SUTURE     IN 

THE    BONE   BOBBIN.  OPERATION  -                 -  -  308 

71.  I  Ilol    STAGE    OF    THE    BUTTON    OPERATION  -  309 

72.  I.\>1     STAGES    OF    THE    BUTTON    OPERATION  -  310 

73.  DECALCIFIED    HONE    BOBBINS  SHOWING  VARIOUS  SIZES  USED 

IN    GALL-BLADDER,    STOMACH,    AND    INTESTINAL    OPERA- 

l  IONS  -  -  -      317 


DISEASES  OF  THE  GALL-BLADDER 
AND  BILE-DUCTS 

CHAPTER   I 

ANATOMICAL  CONSIDERATIONS 

The  gall-bladder  is  situated  on  the  inferior  surface  of  the 
right  lobe  of  the  liver  in  a  large  but  shallow  depression  termed 
the  cystic  fossa,  the  peritoneum  covering  the  under  surface 
of  the  liver  being  reflected  on  to  and  covering  the  unattached 
fundus  and  inferior  surface. 

The  gall-bladder  is  usually  pear-shaped,  the  large  extremity 
lying  anterior  to  and  below  the  neck,  where  it  merges  in  the 
cystic  duct.  It  varies  considerably  in  size  according  to  the 
volume  of  its  contents.  In  a  state  of  moderate  distension  it 
holds  from  50  to  60  c.c.  of  bile.  Its  walls  are  very  elastic, 
and  it  is  possible  to  introduce  under  pressure  from  200  to 
250  c.c.  of  water  without  producing  rupture.  If  the  distension 
is  continued,  rupture  occurs  close  to  the  neck  of  the  organ. 

The  gall-bladder  is  divided  into  three  portions,  the  fundus, 
the  body,  and  the  neck,  the  latter  being  continuous  with  the 
cystic  duct. 

The  rounded  fundus  projects  beyond  the  free  border  of 
the  liver,  the  margin  of  which  presents  a  more  or  less 
distinct  notch — the  cystic  notch — and  comes  into  contact 
with  the  anterior  abdominal  wall  close  to  the  anterior 
extremity  of  the  ninth  or  tenth  costal  cartilage.  Practically, 
the  fundus  of  the  gall-bladder  lies  immediately  below  the 

1 


2     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


point  where  the  outer  edge  of  the  rectus  abdominis  muscle 
crosses  the  costal  margin. 

The  body  of  the  gall-bladder  presents  two  aspects,  a 
superior  and  an  inferior.  The  superior  surface  is  in  contact 
with  the  cystic  fossa,  to  which  it  is  united  by  some  loose  con- 
nective tissue  and  by  vessels  passing  between  the  gall-bladder 
and  the  liver. 


Fig. 


-Gall-Bladder  and  Bile-Ducts. 


The  lower  surface  is  covered  by  peritoneum  in  its  whole 
extent.  It  lies  in  contact  with  the  second  part  of  the 
duodenum  and  with  the  transverse  colon.  Its  relations, 
however,  vary  considerably  according  to  the  state  of  dis- 
tension of  the  organ.  It  may  be  pushed  upwards  and  lie  in 
contact  with  the  first  part  of  the  duodenum,  with  the  pylorus, 
or  with  the  anterior  surface  of  the  stomach  ;  or  it  may  be 


ANATOMICAL  CONSIDERATIONS  3 

displaced  downwards  and  lie  in  contact  with  the  ascending 
colon  or  the  anterior  surface  of  the  right  kidney.  Occasionally 
a  fold  of  peritoneum  connects  the  body  of  the  gall-bladder  to 
the  anterior  aspect  of  the  transverse  colon. 

The  neck  of  the  gall-bladder  is  the  narrowest  part  of  the 
organ.     It  is  bent  into  the  shape  of  the  letter  S,  and  main- 


Fig.  2.--  Diagram  showing  Relation  of  Gall-Bladder  to  Surface. 


tained  in  this  position  by  loose  connective  tissue  and  by  the 
peritoneum  which  covers  it.  Internally,  two  inflections  give 
rise  to  the  formation  of  two  valves  of  mucous  membrane, 
the  lower  of  which  separates  the  gall-bladder  from  the  cystic 
duct. 

The  wall  of  the  gall-bladder  is  composed  of  three  layers,  a 
serous  coat,  a  nbro-mu,scular  coat,  and  a  mucous  membrane. 

i — 2 


4     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

The  serous  covering  is  continuous  with  the  peritoneum 
covering  the  under  surface  of  the  liver.  It  covers  all  that 
portion  of  the  gall-bladder  which  is  not  in  contact  with  the 
cystic  fossa.  The  fundus  of  the  gall-bladder  is  completely 
covered  by  peritoneum,  and  its  upper  surface,  unlike  the 
body  of  the  organ,  is  not  in  direct  contact  with  the  surface 
of  the  liver.  It  is  separated  by  a  double  serous  fold,  the 
angle  of  which  is  formed  by  the  reflection  of  the  peritoneum 
from  the  margin  of  the  liver  on  to  the  fundus  of  the  gall- 
bladder. 

Occasionally  the  gall-bladder  is  completely  invested  by 
peritoneum,  there  being  on  the  upper  aspect  a  distinct 
mesentery,  which  allows  more  or  less  free  movement.  This 
condition  is,  in  my  experience,  both  on  the  operating-table 
and  in  the  dissecting-room,  an  extremely  rare  one,  but 
Dr.  Brewer  ('  Annals  of  Surgery,'  June,  1899)  estimates  it 
as  occurring  in  50  per  cent,  of  all  cases.  In  3  cases  out  of 
100  examined  by  Dr.  Brewer,  a  mesentery  was  formed  on  the 
lower  surface  by  an  extension  outwards  of  the  free  border  of 
the  lesser  omentum  to  the  fundus,  a  condition  also  described 
by  the  late  Mr.  Greig  Smith.  A  much  more  common  con- 
dition found  on  the  operating-table  is  the  presence  of  a 
mesentery,  not  reaching  the  fundus,  but  extending  to  the 
lower  third  or  half  of  the  gall-bladder. 

The  nbro-muscular  coat  is  composed  of  fibrous  tissue,  with 
an  internal  covering  of  irregularly  disposed  muscular  tissue, 
the  fibres  of  which  run,  some  transversely,  some  longitudi- 
nally, and  some  obliquely. 

The  mucous  membrane  covers  the  whole  of  the  internal 
aspect  of  the  gall-bladder,  and  is  continuous  at  the  neck  of 
the  organ  with  the  mucous  membrane  lining  the  cystic  duct. 
When  the  organ  is  empty  it  is  thrown  into  numerous  folds, 
which  become  effaced  on  distension.  In  addition  to  the 
temporary  folds  there  are  permanent  ridges,  which  divide  the 
mucous  membrane  into  triangular,  quadrangular,  or  polygonal 
areas.  It  possesses  a  fibrous  and  an  epithelial  stratum,  the 
latter  being  formed  by  a  single  layer  of  cylindrical  cells. 

The  mucous  membrane  of  the  gall-bladder  is  richly  studded 
with    glands  resembling   those  found   in    the    biliary   ducts. 


ANATOMICAL  CONSIDERATIONS  5 

They  are  lined  with  cells  similar  in  every  respect  to  those 
of  the  intervening  mucous  membrane,  and  secrete  mucus. 

Obstruction  of  the  cystic  duct,  while  it  probably,  to  a 
certain  extent,  interferes  with  this  function,  does  not  entirely 
do  away  with  it  ;  hence  in  mechanical  obstruction  it  is 
common  to  have  the  gall-bladder  distended  to  a  varying 
extent  with  clear,  translucent,  glairy  fluid.  The  usual 
capacity  of  the  cyst  is  said  to  be  about  6  drachms,  but  it  is 
not  infrequently  distended  so  as  to  hold  over  a  pint  of  fluid, 
while  several  cases  are  on  record  of  tumours  due  to  dilated 
gall-bladders  reaching  such  dimensions  as  to  have  been 
operated  on  by  surgeons  under  the  impression  that  they 
were  ordinary  ovarian  tumours.  When  moderately  dis- 
tended, it  is  usually  to  be  felt  in  the  direction  of  a  line 
drawn  from  the  ninth  or  tenth  costal  cartilage  and  passing 
somewhat  to  the  right  of  the  umbilicus  ;  but  this  position 
may  be  altered  from  an  unusual  size  of  the  left  lobe,  or  other 
structural  variations  of  the  liver,  so  that  it  may  even  project 
into  the  right  lumbar  region.  On  the  other  hand,  especially 
where  there  have  been  repeated  attacks  of  gall-stone  colic 
extending  over  a  long  period,  it  is  more  usual  to  find  the 
gall-bladder  smaller  than  normal,  and  occupying  a  position 
just  in  front  of  the  transverse  fissure  of  the  liver.  So  far 
may  this  contraction  go  that  there  may  be  almost  complete 
obliteration  of  the  sac,  a  condition  which,  when  extreme, 
may  be  described  as  cholecystitis  obliterans.  In  these  cases 
there  is  not  infrequently  increased  difficulty  in  recognising 
the  true  relation  of  the  parts,  from  the  adhesions  of  some  of 
the  surrounding  organs  by  more  or  less  intimate  bonds  to 
the  gall-bladder  and  liver,  so  as  completely  to  hide  the  gall- 
bladder from  view  when  the  peritoneal  cavity  is  opened. 

With  cirrhosis  of  the  liver  the  gall-bladder  is  carried  up 
well  under  the  ribs,  while,  if  the  liver  is  enlarged  from  any 
cause  or  displaced  downwards  by  emphysema  of  the  lungs, 
the  gall-bladder  will  be  pushed  to  a  lower  level.  We  have 
seen  it  in  the  caecal  region  and  even  in  the  pelvis. 

Similarly,  in  diseased  conditions  considerable  variations 
occur  in  the  size  and  relation  of  the  ducts.  It  is  not  at  all 
unusual  for  the  common  duct  to   be  sufficiently  dilated  to 


6    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

permit  a  gall-stone  half  an  inch  or  more  in  diameter  to  'float ' 
in  it,  and  stones  quite  as  large  as  that  have  been  at  times 
extracted  from  the  cystic  duct.  More  rarely  the  hepatic 
duct  also  is  enlarged  sufficiently  to  admit  the  finger.  In  a 
few  cases  there  has  been  noted  congenital  absence  of  the 
gall-bladder,  and  in  these  the  hepatic  duct  and  its  sub- 
divisions in  the  liver  have  been  found  dilated. 

The  blood-supply  of  the  gall-bladder  is  derived  from  the 
cystic  artery,  a  branch  of  the  right  division  of  the  hepatic 
artery.  This  vessel  runs  by  the  side  of  the  cystic  duct  to  the 
neck  of  the  gall-bladder,  and  there  divides  into  two  branches, 
an  internal  and  an  external,  which  run  on  either  side  of  the 
viscus  to  the  fundus.  In  addition,  the  gall-bladder  receives 
some  very  fine  branches,  which  come  directly  from  the  liver. 

The  cystic  veins  enter  the  right  branch  of  the  portal  vein. 
The  nerve-supply  is  derived  from  the  coeliac  plexus  of  the 
sympathetic. 

The  cystic  duct  extends  from  the  gall-bladder  to  the  termi- 
nation of  the  hepatic  duct,  with  which  it  unites  to  form  the 
common  bile-duct.  It  is  from  33  to  45  millimetres  in  length, 
and  has  a  diameter  of  from  3  to  4  millimetres,  being  narrowest 
at  the  point  where  it  joins  the  hepatic  duct.  It  resembles  in 
structure  the  wall  of  the  gall-bladder,  and  presents  a  con- 
voluted appearance,  owing  to  the  infolding  of  the  mucous 
membrane  in  the  form  of  valves  in  the  interior  (Fig.  3). 

The  hepatic  duct  originates  at  the  right  extremity  of  the 
transverse  fissure  of  the  liver  by  the  junction  of  the  two  or 
three  terminal  biliary  ducts.  Thence  it  runs  downwards 
and  a  little  from  right  to  left,  to  terminate  in  the  common 
bile-duct.  The  diameter  of  the  duct  measures  from  4  to  5 
millimetres.  Its  length  is  at  least  3  centimetres,  but  it  varies 
considerably  in  different  subjects.  These  variations  depend 
on  one  or  other  of  the  two  following  conditions :  the 
uncertain  point  of  junction  of  the  terminal  biliary  ducts, 
and  the  high  or  low  union  of  the  cystic  duct. 

Very  rarely  the  terminal  biliary  ducts,  two  or  three  in 
number,  unite  directly  with  the  cystic  duct  to  form  the 
common  bile-duct.  In  such  a  case  the  hepatic  duct  does  not 
exist.      In    its   whole    course    the    hepatic    duct    is    situated 


ANATOMICAL  CONSIDERATIONS 


between  the  two  layers  of  the  gastro-hepatic  omentum. 
Above,  at  its  origin,  it  crosses  perpendicularly  on  their 
anterior  aspect  the  right  branches  of  the  hepatic  artery  and 
the  portal  vein.  Below,  it  runs  on  the  antero-external  aspect 
of  the  portal  vein,  which  position  it  maintains  to  its  termina- 
tion. It  is  in  intimate  relationship  with  the  lymphatic 
glands  at  the  hilum  of  the  liver,  and  also  with  the  nerves 
running  to  the  liver. 


Fig,  3.  —  Diagram  to  show  convoluted  appearance  of  Cystic  Duct. 

(Modified  from  Testut.) 

The  wall  of  the  hepatic  duct  is  composed  of  two  layers,  an 
external  and  an  internal. 

The  external  is  formed  of  connective-tissue  and  elastic  fibres, 
with  a  few  longitudinally  disposed  unstriped  muscular  fibres. 

The  internal  is  composed  of  mucous  membrane  lined  with 
finely  granular  cells.  The  mucous  membrane  shows  a 
number  of  small  lateral  diverticula,  which  correspond  exactly 
to  those  found  in  the  intra-hepatic  ducts. 

The  blood-supply  and  innervation  of  the  hepatic  duct  are 
the  same  as  those  of  the  common  duct.  The  arteries  are 
branches  of  the  hepatic  artery.     The  veins  join  the  portal 


8     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

vein.     The  lymphatics  run  to  the  glands  in  the  hilum  of  the 
liver,  and  the  nerve-supply  is  from  the  hepatic  plexus. 

The  common  bile-duct  results  from  the  junction  of  the 
cystic  duct  with  the  hepatic  duct ;  it  receives  the  bile  from 
these  two  canals,  and  transmits  it  into  the  second  portion  of 
the  duodenum.  It  runs  in  a  direction  continuous  with  that 
of  the  hepatic  duct  from  above  downwards  a  little  from  right 
to  left,  running  behind  the  first  part  of  the  duodenum  to  the 
upper  border  of  the  head  of  the  pancreas.     Then  it  turns  a 


?  A 


PV  - 


Fig.  4. — Diagram  of  Common  Bile-duct. 
(Modified  from  Testut.) 

little  to  the  right  and  forwards  within  the  pancreas  to  the 
postero-internal  aspect  of  the  second  portion  of  the  duodenum. 
It  traverses  the  wall  of  the  intestine,  into  which  it  opens. 
It  may  be  divided  into  four  parts  (Fig.  4) : 

1.  The  supraduodenal. 

2.  The  retroduodenal. 

3.  The  pancreatic. 

4.  The  intraparietal. 

The  canal  in  its  entirety  describes  a  curve:  with  the  con- 
cavity to  the  right.     It  varies  in  length  from  6  to  8  centi- 


ANATOMICAL  CONSIDERATIONS 


metres,  while  its  diameter  is  a  little  greater  than  that  of  the 
hepatic  duct.  According  to  Quenu,  an  average  taken  from 
twenty  subjects  gives  the  circumference  of  the  duct  as 
13  millimetres.  The  common  duct  is  very  extensile,  as  are 
also  the  other  biliary  ducts,  and  in  cases  of  calculus  and 
malignant  obstruction  the  common  duct  may  attain  a  very 
considerable  size,  so  as  to  resemble  in  calibre  the  small  or 
even  the  large  intestine. 

The  relations  of  the  common  bile-duct  are  of  extreme 
importance  in  view  of  the  various  operations  which  are 
performed  for  the  relief  of  obstruction  in  the  duct. 

The  supraduodenal  portion  measures  from  10  to  14  milli- 
metres in  length,  though  it  may  be  shorter  or  longer,  according 
to  the  point  of  junction  of  the  hepatic 
and  cystic  ducts.  It  runs  in  the  free 
border  of  the  gastro-hepatic  omentum 
immediately  in  front  of  the  foramen 
of  Winslow.  Here  it  lies  on  the 
antero-external  aspect  of  the  portal 
vein,  while  the  hepatic  artery  is  to  its 
inner  side.  A  small  branch  of  the 
pancreatico-duodenal  artery  crosses 
this  part  of  the  duct  just  above  the 
duodenum.  A  chain  of  three  or  four 
lymphatic  glands  lies  in  contact  with 

the     supraduodenal      portion    of     the    the  foramen  of  Winslow. 

common  bile-duct,  their  vessels  passing  to  the  glands  in  the 
transverse  fissure  of  the  liver. 

The  retroduodcnal  portion  corresponds  to  the  posterior 
aspect  of  the  first  part  of  the  duodenum,  to  the  wall  of  which 
it  is  closely  applied.  The  portal  vein  lies  to  its  inner  side, 
while  behind  it  is  the  inferior  vena  cava. 

The  pancreatic  portion  is  the  name  applied  to  that  portion 
of  the  common  bile-duct  which  extends  from  the  inferior 
border  of  the  first  part  of  the  duodenum  to  the  point  where 
the  duct  penetrates  the  wall  of  the  second  part ;  it  measures 
from  20  to  25  millimetres  in  length.  This  portion  of  the 
common  duct  crosses  a  small  quadrilateral  area,  bounded 
above  by  the  inferior  border  of  the  first  part  of  the  duodenum. 


Fig.  5. — Section  of  the 
Free  Border  of  the 
Lesser  Omentum,  show- 
ing the  Relations  of 
the  Common  Bile-duct. 

ha,  Hepatic  artery ;  d,  bile- 
duct;  pv,  portal  vein  ;  vc,  vena 
cava.      The  arrow   indicates 


io    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

below  by  the  superior  border  of  the  third  part,  externally  by 
the  internal  border  of  the  second  part,  and  internally  by  the 
superior  mesenteric  vein  (Quenu,  Revue  de  Chirurgie,  1895). 
It  is  here  closely  applied  to  the  pancreas,  in  some  cases  being 
completely  surrounded  by  pancreatic  tissue,  in  others  lying 
in  a  pronounced  groove  on  the  posterior  surface  of  the  gland. 
Bunger  (Med.  Press,  p.  523,  1902),  in  a  careful  examination 
of  fifty-eight  subjects,  found  in  25  per  cent,  the  duct  ran 
in  a  groove  in  the  gland,  while  in  75  per  cent,  it  was 
completely  enclosed  by  pancreatic  tissue. 


Fig.  6. — Diagram  to  show  the   Ampulla   of  Vater  with  the  ordinary 
termination  of  the  common  blle-duct  and  the  duct  of  wlrsung. 

(Modified  from  Testut.) 

According  to  O.  Wyss,  the  common  bile-duct  ran  in  a 
groove  on  the  posterior  surface  of  the  head  of  the  pancreas  in 
fifteen  out  of  twenty-two  bodies  examined  (68*  1  per  cent.), 
and  it  was  surrounded  by  the  tissue  of  the  pancreas  on  all 
sides  in  the  other  seven  bodies  (517  per  cent.).  This  ana- 
tomical condition  is  important,  inasmuch  as  swelling  of  the 
pancreas  will  in  the  first  case  push  the  common  duct  out  of 
the  way  without  compressing  it,  while  in  the  second  case 
compression  leading  to  occlusion  may  easily  take  place  where 
the  duct  passes  through  the  head  of  the  pancreas. 

This  portion  of  the  common  duct  is  in  close  relationship 
with  the  inferior  vena  cava. 


ANATOMICAL  CONSIDERATIONS  II 

The  intraparietal  or  interstitial  portion  of  the  common  duct 
comprises   all    that   portion  of  the   canal  contained    in   the 
thickness  of  the  wall  of  the  duodenum.     It  passes  obliquely 
through  the  muscular  coat  of  the  intestine,  and  then  dilates 
into  a  little  reservoir  underneath  the  mucous  membrane,  into 
which  the  main  pancreatic  duct  also  opens.     This  is  known 
as  the  ampulla  of  Vater.     This  ampulla,  a  little  oval  cavity, 
may  be  well  seen  in  a  section  of  the  wall  of  the  duodenum  in 
the  axis  of  the  common  duct  (Fig.  6).     The  opening  of  the 
common  duct  is  above  that  of  the  pancreatic  duct,  and  the 
two  are   separated  by  a    little   transverse   fold   of   mucous 
membrane.    The  ampulla  measures  from  6  to  7  millimetres  in 
length,  and  from  4  to  5  in  breadth,  and,  with  the  termination 
of  the  two  ducts,  is  surrounded  by  a  thin  layer  of  unstriped 
muscular  tissue,  forming  a  sphincter  (Oddi).      The  ampulla 
opens  into  the  duodenum  by  a  little  round  or  elliptical  orifice, 
which   is  the    narrowest   part   of  the   bile   channel.      It  is 
important  to  note  that  the  length  of   the  diverticulum  of 
Vater  may  vary  from  zero  to  11   millimetres,   the  average 
being   3*9    millimetres,   according   to    Opie,  who   measured 
100  specimens.     Viewed  from  the  interior  of  the  duodenum 
the  ampulla  forms  a  rounded  eminence  of  the  mucous  mem- 
brane, known  as  the  caruncula  major  of  Santorini,  the  open- 
ing being  seen  at  the  apex  of  the  caruncle.     It  is  distant 
8  to   12  centimetres  from   the  pylorus.      Above  it  there  is 
constantly  found  a  small  transverse   fold   of  mucous  mem- 
brane, which  must  be  raised  in  order  that  the  caruncle  and 
its  orifice  may  be  clearly  seen.     Running  downwards  from 
the  caruncle  is  a  small  vertical  fold  of  mucous  membrane 
known  as    the   frenum    carunculae.      Above   the    caruncula 
major  is  found  a   smaller   eminence,    the   caruncula   minor, 
marking  the  termination  of  the  accessory  pancreatic  duct. 

An  accessory  pancreatic  duct  or  duct  of  Santorini  opens 
into  the  duodenum  about  f  of  an  inch  above  the  biliary 
papilla ;  it  is  patent  in  about  50  per  cent,  of  cases,  and  in 
over  80  per  cent,  of  cases  it  communicates  with  the  duct 
of  Wirsung. 

The  mode  of  formation  of  the  ampulla  of  Vater  and  the 
termination  of  the  common  and  pancreatic  ducts  are  liable 


12    DISEASES  OF  THE  GALL-BLADDER  AXD  BILE-DUCTS 


-CD 


to  great  variations.     Letulle  and  Nattan  Lorrier  distinguish 
four  types. 

The  first  type  is  the  classical  one  described  above. 

In  the  second  type  the  pancreatic 
duct  joins  the  common  duct  some 
little  distance  from  the  duodenum  ; 
the  ampulla  of  Yater  is  absent,  and 
the  duct  opens  into  the  duodenum  by 
a  small  flat,  oval  orifice  (Fig.  7). 

In    the   third  type    the   two   ducts 

open  into  a  small  fossa  in  the  wall  of 

the  duodenum,  while  the  caruncle 

and  the  ampulla  of  Yater  are  both 

absent  (Fig.  8). 

In  the  fourth  type  the  caruncle 
is  well  developed,  but  the  ampulla 
of  Vater  is  absent,  the  two  ducts 
opening  side  by  side  at  the  apex 
of  the  caruncle  (Fig.  9). 

In  structure  the  common  duct 
resembles  the  other  biliary  ducts,  its 
blood-supply  and  innervation  being 
the  same  as  those  of  the  hepatic 
duct. 

Congenital  Malformations.  — There 
P  is  apparently  no  part  of  the  biliary 

\  ~  P  apparatus,   except  the  liver,  which 

may  not  be  absent.  While  this  is 
not  to  be  wondered  at  in  the  case  of 
the  gall-bladder  and  cystic  duct — 
as  in  Specimen  Xo.  1,^90  in  Guy's 


--PD 


Three  Other  Types  of  Ter- 
mination of  the  Common 
Bile-duct. 

cd,  Common  bile-duct ;  pd, 
pancreatic  duct;  <>,  common 
orifice;  c,  cup-shaped  depres- 
sion in  wall  of  duodenum  ;  p, 
papilla. 


Museum    (see   Fig.  J4,   p.  75),   in 


one  specimen  in  St.  Thomas's,  in 
two  at  the  museum  of  the  Middle- 
sex Hospital,  and  in  Specimen 
No.  1,391  in  Royal  College  of  Surgeons'  Museum  (see  Fig.  25, 
p.  75) — since  they  are  normally  wanting  in  certain  animals 
and  are  frequently  obliterated  by  disease  in  the  human 
subject,  it  affords  serious  food  for  thought  to  find  that  life 


ANATOMICAL  CONSIDERATIONS  13 

has  been  possible  for  six  months  where  even  the  hepatic  and 
common  ducts  are  represented  by  mere  fibrous  cords,  as 
in  Specimen  No.  973  in  St.  Mary's  (see  Fig.  22,  p.  68),  and 
No.  1,017  in  King's  College  Museums.  The  subject  is  treated 
of  in  a  separate  chapter  (p.  66)  as  Obliterative  Cholangitis. 

Hourglass-shaped  gall-bladder  is  probably  not  uncommon. 
I  have  operated  on  several. 

Occasionally  the  distal  part  of  the  gall-bladder  contains 
calculi,  and  communicates  by  a  narrow  neck  with  the  cyst 
proper,  or  the  distal  portion  may  simply  contain  mucus  and 
the  proximal  sac  one  or  more  calculi. 

In  some  instances  the  condition  arises  from  contraction  of 
an  old  ulcer,  but  in  others  (as  in  Case  90),  the  mucous  mem- 
brane being  smooth,  and  showing  no  evidence  of  cicatriza- 
tion, the  deformity  appears  to  have  been  congenital. 
Dr.  Pilcher  has  described  a  case  belonging  to  the  latter 
category,  and  another  has  been  published  by  Dr.  H.  C. 
Donald,  of  Paisley,  in  which  the  gall-bladder  was  found  to  be 
1  thickened  and  contracted,  being  firmly  adherent  to,  and 
tucked  up  to,  the  under  surface  of  the  liver.  It  was  dis- 
tinctly hourglass  in  character,  and  contained  thick,  clear, 
and  glairy  mucus.  Two  calculi  were  removed  from  the 
proximal  part  of  the  gall-bladder,  which  was  separated  from 
the  distal  by  a  narrow  neck,  the  calibre  of  which  would 
admit  a  long  probe,  such  as  is  used  in  exploring  the  ducts. 
He  adds  :  '  I  cannot  advance  an  opinion  as  to  whether 
this  condition  of  gall-bladder  was  congenital  or  due  to 
ulceration.' 

A  curious  malformation  is  seen  in  Specimen  No.  1,391 
in  Guy's  Museum,  in  which  the  gall-bladder  is  dilated  and 
turned  to  the  left,  forming  an  ovoid  tumour  3  inches  long, 
parallel  with  and  projecting  beyond  the  anterior  edge  of  the 
liver. 

The  accompanying  drawing  (Fig.  10)  is  taken  from  a 
specimen  of  bifid  gall-bladder  of  a  sheep  presented  to  me 
by  Dr.  Beatson  of  Glasgow,  but  the  condition  is  only  rarely 
seen  in  the  human  subject. 

In  the  Annals  of  Surgery  for  May,  1899,  *s  related  a  case  in 
which  there  was  transposition  of  viscera ;  and  as  the  patient 


14     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

was  the  subject  of  gall-stones,  cholecystotomy  was  success- 
fully performed  on  the  left  side. 

In  palpating  the  common  duct  for  gall-stones,  the  surgeon 
frequently  feels  several  more  or  less  hard  nodules  within  the 
free  border  of  the  lesser  omentum,  by  the  side  or  in  front  of 
the  common  duct,  and  unless  it  be  borne  in  mind  that  three 
or  four  lymphatic  glands  normally  exist  here,  they  may  be 
apt  to  mislead,  especially  as  they  are  not  unusually  consider- 
ably enlarged  where  there  is  gall-stone  irritation.  Frequently 
they  are  as  large  as  beans,  and  at  times  the  size  of  filberts. 


CROSS  SECTION  — 


-LEVEL   OF 
SEPTUM. 


Fig.   io. — Bifid  Gall-bladder  from  a  Sheep. 
(Leeds  Museum.) 


No.   2,809,    Hunterian   Museum,   shows    these  glands  much 
enlarged  and  melanotic  (Fig.  11). 

The  large  peritoneal  pouch,  bounded  above  by  the  right 
lobe  of  the  liver,  below  by  the  ascending  layer  of  the  trans- 
verse mesocolon  covering  the  duodenum  internally,  externally 
by  the  peritoneum  lining  the  parietes  down  to  the  crest  of 
the  ilium,  posteriorly  by  the  ascending  mesocolon  covering 
the  kidney,  and  internally  by  the  peritoneum  covering  the 
spine,  has  been  long  recognised,  but  perhaps  not  sufficiently 
appreciated  in  gall-bladder  surgery.    Mr.  Rutherford  Morison 


PLATE   I. 


Fig.  ii. — Melanotic  Tumour  of  Gall-bladder  and  Glands 
in  Portal  Fissure. 


(No.  2,809,  Hunterian  Museum.) 


To  face  p.  14.] 


ANATOMICAL  CONSIDERATIONS  15 

drew  attention  to  it  in  a  paper  in  the  British  Medical  Journal 
for  March  3,  1894  (see  Fig.  68,  p.  292). 

It  is  possible  to  drain  this  pouch  satisfactorily  by  means  of 
a  long  glass  tube,  but  it  is  probably  safer,  on  the  whole,  to 
make  use  of  a  lumbar  drain.  The  author  referred  to,  places 
such  reliance  on  the  ease  and  safety  with  which  it  can  be 
drained  that  he  does  not  advocate  much  time  being  spent  in 
suturing  incisions  in  the  gall-bladder  or  bile-ducts.  It  is 
interesting  to  note  that  the  pouch  is  capable  of  holding 
nearly  a  pint  of  fluid  before  it  overflows  into  the  general 
peritoneal  cavity  through  the  foramen  of  Winslow  or  over 
the  pelvic  brim. 

A  deformity  of  the  liver,  congenital  or  acquired,  may  at 
times  lead  to  a  difficulty  in  diagnosis  or  in  treatment.  The 
common  form  is  a  tongue-shaped  prolongation  of  the  right 
lobe,  which  may  project  below  the  costal  margin  for  several 
inches,  and  simulate  a  tumour  of  the  liver  or  an  enlarged 
gall-bladder. 

One  form  of  the  enlargement  shown  in  Cruveilhier's  Atlas 
is  supposed  to  have  been  due  to  tight-lacing  ;  it  was  associated 
with  dropsy  of  the  gall-bladder  and  gall-stones. 

In  some  instances  the  gall-bladder  projects  beyond  the 
apex  of  the  linguiform  projection,  in  others  the  dilated  gall- 
bladder lies  under  cover  of  the  projecting  lobe,  which  is 
thinned  and  spread  out  over  it. 

In  Case  234  the  gall-bladder  and  linguiform  process  of  the 
liver  reached  the  caecal  region,  and  the  recurrent  attacks  of 
pain,  associated  with  local  peritonitis  and  unaccompanied  by 
jaundice,  much  resembled  recurring  appendicitis,  the  point 
of  greatest  tenderness  being  situated  midway  between  the 
umbilicus  and  anterior  superior  spine  of  the  ilium,  in  which 
position  the  incision  for  the  operation  was  made. 

In  others,  the  projection  is  external  to  the  gall-bladder, 
which  is  then  found  lying  on  its  inner  side  (Figs.  12  and  13). 

In  a  case  of  this  kind,  where  the  gall-bladder  is  contracted 
and  calculi  are  impacted  in  the  cystic  duct,  there  may  be 
the  greatest  difficulty  in  extracting  them,  owing  to  a  limita- 
tion of  the  space  for  manipulation,  caused  by  the  abnor- 
mality, unless  the  liver  be  lifted  up  as  described  on  p.  250. 


Fig.   12.  —  Linguiform  Process  of  Liver. 


Fig.  13. — Linguiform  Process  of  Liver. 


ANATOMICAL  CONSIDERATIONS  17 

We  believe  that  Professor  Riedel  first  described  this  lingui- 
form  projection  of  the  liver,  which  is  sometimes  known  as 
Riedel's  lobe.  It  is  said  to  be  uniformly  due  to  cholelithiasis, 
but  that  it  is  not  always  associated  with  gall-stones  our  ex- 
perience in  several  cases  demonstrates. 

The  liver  is  sometimes  displaced  vertically,  as  in  Cases  207 
and  270,  where  the  incision  had  to  be  prolonged  quite  up  to  the 
ensiform  cartilage,  in  order  to  reach  the  shrunken  gall-bladder, 
lying  under  cover  of  the  right  lobe,  the  '  under '  surface  of 
which  faced  to  the  left  side.  In  this  case  the  left  lobe  was 
much  smaller  than  the  right,  which  formed  the  great  bulk 
of  the  liver. 

In  one  case  the  left  lobe  was  apparently  wanting,  and  the 
gall-bladder  was  deeply  placed  under  the  right  lobe,  which 
faced  to  the  left. 

There  have  been  several  cases  reported  where  the  distended 
gall-bladder  projected  into  the  loin,  and  was  reached  and 
evacuated  through  a  lumbar  incision,  the  condition  of  liver 
just  described  being  the  probable  cause  of  the  distortion. 

Dr.  J.  F.  Baldwin  of  Columbia,  Ohio,  has  furnished  me 
with  the  notes  of  a  case  that  came  under  his  care  in  which 
the  liver  was  malformed,  there  being  practically  no  left  lobe, 
and  the  gall-bladder,  instead  of  occupying  the  usual  position 
on  the  under  surface  of  the  right  lobe,  passed  downwards 
and  backwards,  and  lay  just  to  the  right  of  the  vertebral 
column,  in  which  situation  it  was  opened  with  difficulty  for 
the  removal  of  gall-stones,  and  drained. 


CHAPTER  II 

PHYSIOLOGICAL  CONSIDERATIONS 

The  gall-bladder  is  an  appendage  of  the  liver,  and,  so  far  as 
can  be  ascertained,  plays  the  role  of  a  biliary  reservoir,  whose 
function  is  to  store  a  certain  amount  of  the  bile  between 
meals,  and  to  expel  it  during  the  course  of  digestion.  It 
would,  therefore,  be  impossible  to  consider  its  physiology 
without  some  reference  to  that  of  the  fluid  it  holds. 

By  the  kind  permission  of  the  Royal  Society  I  am  permitted 
to  insert  in  this  volume  the  details  of  some  original  observa- 
tions bearing  on  the  physiology  of  the  gall-bladder  and  of 
the  bile  which  I  made  on  cases  of  biliary  and  gall-bladder 
fistulae  in  the  human  subject.  They  were  published  in 
vol.  xlvii.  of  the  Proceedings  of  the  Royal  Society.  (See 
p.  21  et  seq.) 

The  absence  of  the  gall-bladder  in  the  horse  and  some 
other  animals,  and  the  good  health  of  patients  after  its 
removal  by  cholecystectomy,  clearly  prove  that  its  presence 
is  not  essential  to  life ;  but  as  it  is  scarcely  consistent 
with  the  economy  of  Nature  to  provide  beings  with  purpose- 
less organs,  and  since  the  reputed  function  of  the  gall- 
bladder as  a  reservoir  of  the  bile  between  the  periods  of 
digestion  is  both  rational  and  probable,  we  may  accept  the 
theory  until  some  better  one  is  discovered.  But  if  the 
exact  nature  of  its  use  be  not  quite  clear,  we  are  in  no  doubt 
as  to  the  fact  that,  although  gall-stones  are  formed  both  in 
the  liver  and  in  the  gall-bladder,  their  increase  in  size  most 
frequently  occurs  in  the  gall-bladder  alone. 

My  own  experiments,  as  well  as  the  observations  of  others, 
would  lead  one  to  believe  that  the  bile  is  constantly  being 


PHYSIOLOGICAL  CONSIDERATIONS  ig 

excreted.  According  to  Beaunis  ('  Elements  de  Physiologie,' 
p.  718),  the  excretion  in  the  cat  is  effected  under  a  pressure 
of  from  2  to  20  millimetres  of  mercury,  which  slight  pressure 
is  sufficient  to  cause  it  to  be  forced  slowly  into  the  intestine. 

In  all  probability,  after  digestion  is  completed,  the  bile 
flows  into  the  gall-bladder,  and  when  that  organ  is  full  the 
remainder  passes  drop  by  drop  into  the  intestine  ;  but  on 
the  resumption  of  digestion  the  reserve  of  bile  is  gradually 
expelled  by  a  reflex  act. 

Since  gall-stones  are  composed  principally  of  cholesterine, 
frequently  combined  with  bilirubin-calcium-carbonate,  one 
can  easily  understand  how  that,  given  a  nucleus  and  some 
altered  condition  of  bile  leading  to  the  deposition  of  choles- 
terine, the  elements  would  be  present  for  the  more  or  less 
rapid  growth  of  concretions.  This  altered  condition  of  the 
bile  would  seem  in  some  cases  to  be  associated  with  a  gouty 
diathesis. 

As  in  the  subjects  of  cholelithiasis  obstruction  of  the 
common  duct  not  infrequently  occurs,  and  in  consequence 
a  saturation  of  the  system  with  bile,  the  observations  of 
M.  Bouchard  on  the  poisonous  properties  of  bile  have  great 
importance.  He  says  that  the  bile  is  nine  times  more 
poisonous  than  urine,  and  that  4  to  6  c.c.  of  bile  are  sufficient 
to  kill  one  kilogramme  of  body-weight,  so  that  the  liver  of 
a  man  may  form  in  eight  hours  sufficient  poison  to  kill  him. 
My  own  observations  also  support  the  view  that  the  bile  is 
almost  purely  an  excretion. 

One  can  easily  understand,  therefore,  that  obstruction  of 
the  common  duct,  if  at  all  prolonged,  becomes  a  very  serious 
matter,  as,  although  the  re-absorbed  bile  is  partly  thrown 
off  by  the  kidneys,  the  blood  soon  becomes  altered  and  the 
system  poisoned.  Should  the  cystic  duct  be  blocked,  no 
such  immediate  serious  results  ensue,  since  the  bile  can  pass 
on  into  the  intestine  ;  but  as  we  know  that  the  mucous  mem- 
brane of  the  gall-bladder  is  lined  with  mucous  follicles,  which 
continue  to  secrete  even  when  the  normal  function  of  the 
gall-bladder  is  in  abeyance,  it  will  be  easily  understood  how 
a  tumour  may  form  in  such  circumstances,  and  how,  by  a 
constant    accumulation    of  the   gall-bladder   secretion,    this 

2 — 2 


20    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

small  hollow  organ  may  attain  to  an  enormous  size,  and 
may  rupture  either  spontaneously  or  as  the  result  of  some 
blow  or  exertion. 

I  have  in  one  case  seen  a  similar  accumulation  of  fluid  in 
the  liver,  due  to  gall-stones  blocking  the  hepatic  duct ; 
aspiration  led  to  the  diagnosis  of  hydatid  disease,  but 
exploration  revealed  a  dilatation  of  the  hepatic  duct  within 
the  liver  substance,  forming  a  cavity  holding  half  a  pint  of 
fluid  resembling  the  retained  secretion  of  the  gall-bladder. 

M.  A.  Dastre  (Arch,  de  Physiol.,  p.  315,  1890;  Centralb. 
j.  d.  med.  Wissensch.,  No.  30,  1891  ;  and  Brit.  Med.  Joum., 
September,  1891)  finds  that  in  dogs  weighing  from  9  to  14 
kilos  (20  to  30  lbs.),  the  introduction  of  100  to  250  grammes 
of  ox  bile,  or  120  to  230  grammes  of  dog's  bile,  into  the 
stomach  just  before,  or  one  hour  after,  the  taking  of  food, 
does  not  cause  any  disturbance  of  digestion  or  of  the  general 
condition  of  the  animal.  There  is  never  vomiting,  and  at 
most  the  ox  bile  causes  purging.  Five  hundred  grammes 
of  boiled  flesh  were  given  to  a  dog  with  a  gastric  fistula,  and 
one  hour  afterwards  there  were  introduced  into  the  stomach 
through  the  gastric  cannula  100  grammes  of  ox  bile.  A  quarter 
of  an  hour  afterwards  the  gastric  contents  were  yellow  in 
colour,  and  the  filtrate  had  an  acid  reaction  and  contained 
syntonin. 

The  filtrate,  when  added  to  fibrin,  rapidly  dissolved  the 
latter.  An  hour  later  the  gastric  contents  yielded  a  clear 
fluid,  also  of  acid  reaction,  containing  peptone  and  pepsin. 
The  introduction  of  large  quantities  of  bile  into  the  stomach 
is  not  accompanied  by  any  disturbance  or  even  slowing 
of  the  gastric  digestive  process — so  rapid  is  the  secretion 
of  acid  that  the  alkaline  reaction  of  the  bile  is  quickly 
neutralized.  These  results  confirm  those  of  Oddi,  who 
found  that  when  bile  was  discharged  from  the  gall-bladder 
directly  into  the  stomach,  gastric  digestion  was  not  inter- 
fered with.  With  the  view  of  studying  the  respective  parts 
played  by  bile  and  pancreatic  juice  in  the  absorption  of  fats, 
Dastre  made  experiments  on  dogs,  which  were  so  arranged 
that  only  the  upper  half  of  the  duodenum  was  moistened 
with  pancreatic  juice ;  that  is,  only  the  pancreas   discharged 


PHYSIOLOGICAL  CONSIDERATIONS  21 

its  secretion  into  this  part  of  the  gut,  while  into  the  lower 
part  of  the  duodenum — 15  centimetres  below  the  pylorus — 
the  bile  for  the  first  time  entered  the  duodenum.  This  was 
done  by  connecting  the  gall-bladder  to  the  lower  part  of  the 
duodenum,  and  allowing  the  two  to  become  united.  The 
result  was  that  the  digested  food  after  leaving  the  stomach 
was  subjected  to  the  action  of  the  pancreatic  juice  alone  in 
the  upper  half  of  the  duodenum,  while  in  the  lower  half  it 
was,  in  addition,  acted  on  by  the  bile  as  well  as  the  pan- 
creatic juice.  After  the  animals  recovered  from  the  opera- 
tion, and  had  remained  for  months  in  good  condition,  they 
were  given  a  good  meal  of  non-emulsified  fat,  and  were 
killed  by  section  of  the  bulb,  or  narcotized,  and  their 
abdominal  cavity  was  opened.  In  every  case  the  lacteals, 
as  far  down  as  the  middle  of  the  duodenum,  were  transparent, 
and  they  only  became  milky  15  centimetres  below  where  the 
bile  was  poured  into  the  duodenum.  It  would  seem  from 
this  that  the  pancreatic  juice  by  itself  is  unable  in  the  living 
animal  (dog)  to  covert  non-emulsified  fat  into  an  emulsion, 
but  that  for  this  purpose  it  requires  the  aid  of  the  bile.  This 
view  seems  to  be  confirmed  by  the  results  obtained  in  dogs 
with  a  complete  biliary  fistula — that  is,  where  all  the  bile 
was  discharged  externally — for  it  was  found  that  all  the 
lacteal  vessels  were  filled  with  a  transparent  fluid  three  hours 
after  a  hearty  meal  of  non-emulsified  fats.  If,  however, 
emulsified  fats — for  example,  milk — are  given  to  a  dog  with 
a  biliary  fistula,  then,  notwithstanding  the  exclusion  of  the 
bile  from  the  intestine,  the  lacteals  from  the  stomach  to  the 
middle  of  the  large  intestine  are  filled  with  a  milky  fluid. 

Observations  on  the  Secretion  of  Bile  from  a  Case  of  Biliary 
Fistula  and  on  the  Discharge  from  a  Gall-Bladder  Fistula.* 

There  are  few  physiological  questions  on  which  so  much 
doubt  and  disagreement  prevail  as  on  that  of  the  secretion 
and  uses  of  bile,  this  being  especially  marked  when  we  come 
to    compare   the    apparently   contradictory   observations   of 

*  A.  W.  Mayo  Robson,  F.R.C.S.,  from  the  Proceedings  of  the  Royal 
Society,  vol.  xlvii. 


22     DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

various  experimenters  relating  to  the  action  of  drugs  on  the 
biliary  secretion. 

As  the  well-known  experiments  of  Dr.  Rutherford  and 
Messrs.  Prevost  and  Binet  were  conducted  on  the  lower 
animals,  it  may  possibly  account  for  the  difference  between 
their  observations  and  those  recorded  in  this  paper.  From 
the  rarity  of  cases  of  biliary  fistula  in  health)-  human 
subjects,  the  opportunity  has  rarely  occurred  for  a  careful 
analysis  of  fresh  bile  in  sufficient  quantity,  or  for  a  complete 
analysis  of  the  whole  twenty-four  hours'  secretion :  and  in 
all  previous  analyses  no  notice  has  been  taken  of  the  gall- 
bladder secretion. 

In  the  following  cases  the  fistulae  remained  open  for  long 
periods  after  the  initial  operations ;  the  total  flow  of  bile  or 
gall-bladder  secretion  was  carefully  collected  and  accurately 
measured  at  different  times  and  for  many  consecutive  hours 
at  a  time,  and  the  general  good  health  of  the  patients  was 
maintained  throughout. 

Method  of  Collecting. — The  fluid  was  caught  in  a  light 
glass  flask,  into  the  mouth  of  which  it  was  guided  by  means 
of  a  celluloid  cannula,  a  substance  chosen,  after  several  trials 
with  metal  ones,  on  account  of  its  lightness  and  non-irritating 
qualities. 

Case  i. — Biliary  Fistula. — Mrs.  V.  B.,  aged  forty-two,  was 
operated  on  in  January,  1888,  for  the  relief  of  obstruction  in 
the  common  bile-duct.  The  incision  was  made  over  the 
gall-bladder,  which  was  brought  to  the  surface,  relieved  of 
its  contents,  and  opened,  the  margin  being  sutured  to  the 
edge  of  the  abdominal  wound  and  drained.  The  patient 
made  a  good  recovery  from  the  operation  ;  but  a  biliary 
fistula  persisted,  through  which  was  discharged  the  whole  of 
the  bile  for  fifteen  months.  In  order  to  ascertain  that  the 
whole  of  the  bile  secreted  escaped  through  the  fistula,  and 
that  none  entered  the  bowel,  repeated  analyses  of  the  urine 
and  faeces  were  made,  but  no  evidence  of  the  presence  of  bile 
was  obtained  at  any  time.  The  fistula  was  ultimately  closed 
by  stitching  the  gall-bladder  to  the  bowel,  and  making  a 
communication  between  them,  thus  enabling  the  bile  to 
reach  the  intestine  by  another  channel.     A  detailed  descrip- 


PHYSIOLOGICAL  CONSIDERATIONS  23 

tion  of  the  case  will   be  found    in    the  Transactions    of  the 
Royal  Medical  and  Chirurgical  Society  for  1889. 

Influence  of  Biliary  Fistula  on  Digestion  and  Nutrition. — 
During  the  fifteen  months  that  the  fistula  was  open  the 
patient's  digestion  seemed  to  be  unimpaired.  The  appetite 
generally  was  good  ;  there  was  a  craving  for  acids,  such  as 
lemons  and  pickles,  and  a  dislike  to  sweet  foods,  to  meat, 
and  to  fat.  Much  fatty  matter  in  her  food  had  a  marked 
effect,  producing  a  sickly  feeling,  with  loss  of  appetite,  and 
rather  more  fat  than  normal  was  then  noticed  in  the  faeces. 
Her  bowels  were  quite  regular  without  the  use  of  aperients, 
and  the  odour  of  the  faeces  did  not  differ  from  that  of  healthy 
motion.  Menstruation  never  occurred  during  the  time  the 
fistula  was  patent,  but  as  soon  as  the  bile  was  again  turned 
into  the  intestine  the  menstrual  function  became  regular  and 
normal. 

Case  2. — Fistula  of  Gall-bladder,  not  Biliary. — Mrs.  A.,  aged 
thirty-two,  was  operated  on  in  June,  1884,  for  distended 
gall-bladder  due  to  gall-stones,  with  stricture  of  the  cystic 
duct ;  the  patient  made  a  good  recovery  from  the  operation, 
but  a  fistula  of  the  gall-bladder  persisted.  From  this 
opening  a  constant  flow  of  a  clear  and  somewhat  viscid  fluid 
persisted,  which  was  held  to  be  the  normal  secretion  of  the 
gall-bladder,  as  there  was  complete  obstruction  of  the  cystic 
duct,  and  as  no  bile  constituents  were  found  in  the  fluid  at 
the  time  of  the  operation  or  subsequently. 

Analyses  of  the  fluid  from  this  patient  were  made  in 
October,  1885,  and  in  April,  1887,  by  Professor  de  Burgh 
Birch,  of  the  Yorkshire  College  (see  Journal  of  Physiology, 
vol.  viii.,  No.  6),  and  in  March,  1889,  by  Mr.  Fairley,  F.C.S., 
F.R.S.E.  In  the  appended  tables  (pp.  31,  33)  will  be  found 
Mr.  Fairley 's  analysis  of  the  secretion  for  twenty-four  hours 
both  from  the  biliary  and  from  the  gall-bladder  fistula. 

The  alleged  diastatic  action  of  bile  may  possibly  be  due  to 
the  admixture  of  the  secretion  from  the  gall-bladder,  or 
from  the  mucous  glands  in  the  large  bile  -  ducts.  In  the 
gall-bladder  fluid  from  Case  2,  Professor  Birch  found  a 
diastatic  ferment,  concerning  which  he  reported :  '  The 
secretion  cannot  be  regarded  as  having  any  important  part 


24     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

to  play  in  digestion,  the  small  diastatic  action  it  possesses 
on  starch  being  shared  by  many  fluids  in  the  economy,  upon 
which  it  does  not  confer  any  special  digestive  value '  (Journal 
of  Physiology,  vol.  viii.,  No.  6). 

Antiseptic  Action. — In  Case  i  the  value  of  bile  as  an  anti- 
septic in  the  intestine  could  be  tested  only  by  the  character 
of  the  faeces,  which,  over  a  period  of  fifteen  months,  during 
which  no  bile  entered  the  bowel,  did  not  by  odour  or  aspect 
indicate  any  irregular  fermentative  process.     In  Case  2  the 


Turpentine        Jan  1'6-  Jan   13- 

1     '•-  1234  56-7S9  lOlliz    123+56759  101112123  1-5678910111? 

2°3- 


Jan   20  U' 


J<ui   '1  'J 


3<*  S  67  9  SI0IH2 


X  =  Turpentine,    ijivrn    event    5  //our-S. 
Total  -  lo? 

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1    T  I   ■ 

x      J ii/'/k  nil  n  (    ynr/i 


Tntnl      I  <r. 


Fig.   14. 


constant  clean  appearance  of  the  edge  of  the  fistula  suggested 
to  me  the  idea  that  it  might  be  due  to  the  antiseptic  quality 
of  the  gall-bladder  fluid ;  and  the  observation  that  when 
collecting  the  fluid  for  experimental  purposes  I  could  leave 
the  flasks  exposed  to  the  air  for  several  days  without  any 
apparent  change  suggested  the  same  conclusion.  Professor 
Birch,  from  numerous  cultivation  experiments,  came  to  the 
conclusion  that  its  antiseptic  properties  were  slight,  the  want 
of  change  being  rather  due  to  the  poverty  of  the  fluid  in 
nourishing  materials  (Journal  of  Physiology,  vol.  vii.). 


PHYSIOLOGICAL  CONSIDERATIONS  25 

Aperient  Action. — In  Case  I  the  bile  did  not  seem  to  be  at 
all  necessary  as  an  intestinal  stimulant,  for  the  bowels  were 
quite  regular  during  the  whole  of  the  time  that  no  bile  was 
entering  the  intestines. 

Alleged  Action  of  Bile  in  promoting  Absorption. — In  Case  1 
fat  could  apparently  be  digested  in  quantities  sufficient,  not 
only  to  maintain  normal  nutrition  and  good  health,  but  to 
lead  to  an  increase  in  weight.  If  taken  too  freely,  it  seemed 
to  create  disturbances  of  digestion,  and  to  be  passed  in 
rather  larger  quantities  than  usual  in  the  faeces,  as  ascer- 
tained by  careful  observation  and  by  separation  by  means  of 
ether. 

Diet. — Details  of  the  daily  diet  are  given  in  the  tables,  and 
may  be  grouped  as  follows : 

I.  Oct.  24 — 27.     Light  diet.     Broth,  bread,  egg,  tea,  milk,  pudding. 
II.  Oct.  29 — Nov.  4.     Chicken  diet.     Broth,  bread,  egg,   tea,   milk, 
pudding,  with  chicken. 

III.  Nov.  5 — 8.     Potato  diet.     Broth,  bread,  egg,  tea,  milk,  pudding, 

with  potato. 

IV.  Nov.  12.     Meat  diet.     Meat,  bread,  milk,  tea. 

Flow  of  Bile. 

The  tables  appended  (p.  33  et  seq.)  show  the  dates  and 
hours  of  collection,  lasting  over  a  period  of  eight  months,  the 
nature  and  quantity  of  the  diet,  and  the  amount  of  bile 
excreted.  The  charts  (Figs.  14,  15,  and  16)  also  show  the 
dates  of  administering  certain  medicines,  and  their  effect  or 
absence  of  effect  on  the  biliary  secretion. 

In  the  drawing  up  of  the  charts  and  tables  I  have  been 
greatly  assisted  by  my  friend  Mr.  C.  W.  Biden. 

Daily  Quantity  of  Bile  Flow. — In  Case  1  the  quantity  of 
bile  collected  in  twenty-four  hours  on  various  dates  in 
October,  November,  and  December  of  1888,  and  January, 
February,  March,  and  April  of  1889,  varied  from  39*53  ounces 
to  25*86  ounces,  and  averaged  29*98,  or  nearly  30,  ounces. 
In  Case  2  the  gall-bladder  fluid  measured  2*53  ounces  in 
twenty-four  hours. 

Subtracting  this  amount  from  the  twenty-four  hours' 
discharge  in  Case  1,  we  get  the  average  daily  flow  of  bile  as 
27J  ounces. 


26     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


Diurnal  Variation  in  Flow. — The  tables  and  charts  (Figs. 
14,  15,  and  16)  show  distinctly  that  more  bile  is  invariably 
excreted  during  the  day  than  at  night,  the  difference  at 
times  being  as  much  as  5  ounces,  at  others  not  more  than 
3  drachms. 


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In  the  tables  and  charts,  which  show  an  hourly  collection 
for  over  twenty-four  hours  (Figs.  14,  15,  and  16),  it  is  clearly 
seen  that  the  excretion  of  bile  is  continuous  night  and  day. 
These  measurements  were  carefully  and  regularly  made  by 


PHYSIOLOGICAL  CONSIDERATIONS 


27 


the  sisters  in  charge  of  the  ward,  under  the  supervision  of 
the  resident  surgical  officer,  Mr.  H.  Littlewood,  F.R.C.S., 
and  my  house-surgeons,  Mr.  B.  G.  Moynihan,  M.S.,  F.R.C.S., 
and  Mr.  F.  Hudson,  M.R.C.S.,  to  whom  I  am  indebted  for 
the  great  pains  they  took  over  so  long  a  period. 


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Fig.   16 


The  daily  quantity  does  not  correspond  with  the  observa- 
tions of  Von  Wittich  and  Westphalen,  who  reported  a 
collection  of  one  pint  in  the  twenty-four  hours,  with  but 
small  variations  during  ten  days. 

More  solids  are  contained  in  the  bile  by  night  than 
by  day,  as  is  shown  by  the  analysis  of  the  specimens  which 
were    examined    by    Mr.    Fairley.      (See   appended    tables, 

PP.  3i»  33-) 

The  quantity  of  bile  discharged  is  apparently  not  much 

influenced  by  the  ingestion  of  food.  The  reception  of  food 
into  the  stomach  is  generally  contemporaneous  with  a 
marked  decline  in  the  flow  of  bile,  lasting  for  about  two 
hours.  The  colour  of  the  fresh  bile  was  always  green  when 
collected  in  Mrs.  V.  B's.  case,  but  before  exposure  to  the  air  it 
was  of  a  bright  orange  colour.  The  violent  odour  of  turpen- 
tine was  perceived  in  the  bile  soon  after  its  administration. 

The  Effect  of  Drugs  on  the  Bile  Flow. — The  observations 
made  on  the  effect  or  non-effect  of  certain  drugs  on  the 
biliary  secretion  show  results  that  are  at  variance  with 
the  usually  accepted  views  of  the  action  of  medicines  on 
the  liver. 


28    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Calomel. — On  November  7,  1888,  5  grains  of  calomel  were 
administered  at  7  p.m. ;  a  slight  aperient  effect  followed  the 
next  morning,  but  on  comparing  the  amount  of  bile  excreted 
before  and  after,  it  was  found  that  for  ten  hours  before  the 
administration  of  the  calomel,  12  ounces  6  drachms 
20  minims  of  bile  were  excreted ;  and  that  for  ten  hours 
subsequent  to  the  administration  10  ounces  4  drachms 
30  minims  were  excreted — i.e.,  2  ounces  1  drachm  50  minims 
less. 

Euonymin. — On  November  17,  4  grains  of  euonymin  were 
given  at  11.30  a.m.  ;  for  the  four  hours  preceding  the 
administration  5  ounces  4  drachms  9  minims,  and  during 
the  four  hours  subsequent  to  its  administration  5  ounces 
1  drachm  8  minims  were  excreted — i.e.,  3  drachms  less. 
This  dose  was  repeated  on  several  occasions  with  similar 
results. 

Rhubarb. — On  November  13,  at  11  a.m.,  h  ounce  of  tincture 
of  rhubarb  was  administered  ;  during  the  preceding  six  hours 

7  ounces  3  drachms  23  minims  of  bile  were  excreted,  and 
during  the  six  hours  subsequent  to  the  administration  of  the 
drug  7  ounces  4  drachms  19  minims  were  excreted — that  is, 
56  minims  more  in  the  subsequent  than  in  the  preceding  six 
hours.  But  on  comparing  the  corresponding  period  of  the 
previous  day,  when  no    rhubarb  was   given,    we   find   that 

8  ounces  6  drachms  10  minims,  or  1]  ounces  more,  were 
excreted.  Therefore  no  increased  flow  of  bile  can  be  put 
down  to  the  action  of  the  rhubarb. 

On  November  15,  1  ounce  of  rhubarb  was  given.  The 
figures  as  seen  in  the  tables  again  show  a  diminution  com- 
pared with  the  previous  day. 

Podophyllin  was  given  on  one  occasion,  and  no  cholagogue 
effect  was  noticed. 

Carbonate  of  Soda. — Soda  water,  aerated,  was  given,  and 
produced  an  increased  flow.  Its  ingestion  was  followed  in 
two  hours  by  a  maintained  increased  flow,  not  succeeded  by 
a  marked  diminution. 

Iridin. — On  April  16,  4  grains  of  iridin  were  followed  by  a 
good  afternoon  rise  in  the  bile  flow,  but  two  days  later  there 
was  a  much  higher  afternoon  rise,  when  no  drug  had  been 


PHYSIOLOGICAL  CONSIDERATIONS  29 

given.  On  April  19,  4  grains  of  iridin  gave  an  effect 
not  so  pronounced,  the  increased  flow  being  intermittent. 
Apparently,  the  action  of  iridin  is  to  increase  the  flow  tem- 
porarily, without  augmenting  the  total  quantity  in  twenty- 
four  hours. 

Turpentine. — Messrs.  Prevost  and  Binet  state  that  turpen- 
tine and  its  derivatives  promote  a  notable  increase  in  the 
excretion.  In  order  to  test  this,  a  turpentine  capsule,  con- 
taining 15  minims  of  the  oil  of  turpentine,  was  given  every 
four  hours  night  and  day. 

On  January  18  no  drug  given;  27  ounces  6  drachms 
35  minims  were  excreted  in  twenty-four  hours.  On  January  19 
and  20,  during  the  administration  of  turpentine  capsules, 
28  ounces  5  drachms  41  minims  were  excreted  ;  that  is,  an 
increase  of  7  drachms.  During  the  following  twenty-four 
hours,  the  capsules  being  continued,  30  ounces  2  drachms 
to  minims  were  excreted. 

During  the  third  period  of  twenty-four  hours,  with  the 
capsules,  26  ounces  57  minims  were  excreted ;  and  during 
the  fourth  twenty-four  hours  27  ounces  45  minims. 

Therefore,  although  an  increase  was  apparent  on  the 
second  day,  the  daily  amount  of  bile  discharged  in  the 
twenty-four  hours  was  not  so  much  as  on  many  days  when 
no  turpentine  was  being  given,  as,  for  instance,  on 
October  27  and  29,  when  it  was  over  30  ounces. 

Benzoate  of  Soda. — Messrs.  Prevost  and  Binet  state  that 
the  administration  of  benzoate  of  soda  to  dogs  increased  the 
amount  of  bile  to  two  or  three  times  the  normal.  This  I  do 
not  find  to  be  the  result  in  Case  1,  as  the  table  and  charts 
appended  will  show,  where  no  positive  increase  is  seen. 

Conclusions. 

1.  The  bile  is  probably  chiefly  excrementitious,  and, 
like  the  urine,  is  constantly  being  formed  and  cast  out. 

2.  Though  the  bile  probably  assists  in  the  absorp- 
tion of  fats,  its  presence  in  the  intestine  is  not  necessary  for 
the  digestion  of  such  an  amount  of  fat  as  is  capable  of 
supporting  life  and  keeping  up  nutrition. 


30     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

3.  Increase  in  body-weight  and  good  health  are 
quite  compatible  with  the  entire  absence  of  bile  from  the 
intestines. 

4.  The  antiseptic  properties  of  the  bile  are  unim- 
portant. 

5.  Whatever  little  antiseptic  quality  bile  may  have  is 
probably  derived  from  its  admixture  with  the  gall-bladder 
fluid. 

6.  The  supposed  stimulating  effect  of  the  bile  on  the 
intestinal  walls  is  not  necessary  for  a  regular  action  of 
the  bowels. 

7.  The  quantity  of  bile  excreted  in  the  twenty-four 
hours  during  health,  in  a  person  of  average  weight,  may 
vary  between  39  ounces  4  drachms  and  25  ounces  6  drachms, 
with  an  average  of  30  ounces,  less  the  2h  ounces  of  fluid 
secreted  by  the  gall-bladder. 

8.  More  bile  is  excreted  during  the  day  than  at  night, 
the  excess  varying  between  5  ounces  and  3  drachms. 

9.  The  excretion  of  bile  seems  to  go  on  constantly 
and  with  great  regularity. 

10.  The  excretion  is  apparently  not  materially  in- 
fluenced by  diet. 

11.  The   pigment    of    fresh    human    bile    is    bilifulvin. 

12.  The  supposed  cholagogues  investigated  seem  to 
rather  diminish  than  increase  the  amount  of  bile  ex- 
creted. 

Mr.  Fairley's  Analysis. 

Analysis  of  bile  drawn  from  biliary  fistula  (Mrs.  V.  B.), 
collected  April  13,  10  a.m.  to  10  p.m.,  and  April  13  to  14, 
10  p.m.  to  10  a.m.,  1889. 

Columns  I.,  II.,  III.  refer  to  the  whole  bile  and  gall- 
bladder fluid:  Column  I.,  first  twelve  hours;  Column  II., 
second  twelve  hours;  and  Column  III.,  the  whole  fluid  col- 
lected during  twenty-four  hours.  Column  IV.  ^ives  the 
composition  of  the  bile  calculated  without  the  gall-bladder 
fluid. 


PHYSIOLOGICAL  COXSIDERATIONS 


3i 


Quantity 
Specific  gravity 
Reaction 


1. 

12  Hours 

10  a.m.  to 

10  p.m., 

April   13. 

570  C.C. 
1-0085 

Alkaline. 


II. 

12  Hours, 

10  p.m.  to 

10  a.m., 

April  13-14. 

370  C.C. 
I  0090 


The  bile  contains  in  1,000  parts  : 


Water... 
Total  solids 


982*10 
17-90 

J  OOO'OO 


98179 

l8'2I 

I OOO 'CO 


III. 

24  Hours, 
April  13-14. 

940  C.C. 
I  "0087 


981-98 
I8-02 

iooo-oo 


IV. 

24  Hour, 
corrected  for 
Gall-bladder 
Fluid. 

868  C.C. 

roo86 


98176 
18-24 

IOOO"00 


The  solid  matter  of  the  bile  contains  : 


Cholesterine     ... 

Fatty  matter  (free) 

Fat  combined  (chiefly  sodium 
stearate) 

Sodium  glycocholate  ... 

Sulphur  equal  to  sodium  tauro- 
cholate 

Organic  substances  precipi- 
tated by  alcohol,  chiefly 
mucus  and  epithelium 

Chlorides  equal  to  sodium 
chloride 

Carbonates  and  phosphates  of 
sodium,  potassium,  lime, 
magnesia,  and  iron... 

Copper  ... 

Silica 

Sulphates  ) 

Urea  V       

Sugar        J 


I. 

12  Hours, 

10  a.m. 

to  10  p.m.. 

April  13. 

II. 

12  Hours, 

10  p.m. 

to  10  a  m., 

April  13-14. 

in. 

24  Hours, 
April  13-14. 

IV. 

24  Hours, 

corrected  for 

Gall-bladder 

Fluid. 

0-44 

OTI 

0*45 
0"I2 

0'45 
0'12 

0-45 

0-I2 

0*90 
7*45 

ro8 
7 '60 

0-97 
7-5I 

0'97 
7-5I 

0-087 


5-oS 


■52 


0-094 


o'o9 


none 


The  solid  matter  of  the  bile  gave  on  ignition  : 
Ash  per  1,000  parts      8-15  S'68  8-36 


0-09 


1*29 

1-30 

0-85 

4-91 

5-01 

4"95 

2-66 

minute  trace 

trace 

2-57 

2-54 
trace 
trace 

none 


8-34 


The  above  analysis  of  the  bile  was  confirmed  by  a  further 
quantitative  analysis  of  the  bile  taken  five  days  later. 

The  average  quantity  of  bile,  as  ascertained  by  observations 
extending  over  eight  months,  was  30  ounces  (very  nearly 
862  c.c.)  during  twenty-four  hours. 


-V.     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


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PHYSIOLOGICAL  CONSIDERATIONS 


33 


Analysis  of  iluid  from   the  gall-bladder  (collected   during 
twenty-four  hours.     Mrs.  A.).     Received  April  29,  1889. 


Quantity 
Specific  gravity 
Reaction 

The  fluid  contains  in  1,000  parts  : 

Water 

Total  solids*  ... 

The  solid  matter  contains  : 


72  c.c. 
.  1-0095 
Alkaline. 


984-64 


Organic  matter,  chiefly  mucin,  with  trace  of  albumin  6-72 

Chlorides  equal  to  sodium  chloride  ...  ...  5*73 

Sodium  carbonate  ...  ...  ...  ...  2*20 

Other  salts,  containing  phosphates,  potassium  salts,  etc.  071 


Mrs.  V.  B.     Age  Forty-two.     Daily  Excretion  of  Bile. 


Octobev  24 — 

12-1  p.m. 
1-2 

2-3 
3-4 
4-5 
5-6 

6-7 
7-8 
8-9 
9-10 
10-7  a.m.         Milk,  1  pint 


Fish,  6  oz.  ;  pudding 


Tea,  14  oz. ;  bread,  5^  oz. ;  egg, 


Milk,  1 


pint 


7-8 

8-9 

9-10 
10- 1 1 
1 1- 1 2  noon 


Tea,  16  oz. ;  bread,  5^  oz 
Beef  tea,  1  pint 


oz. 

dr. 

min 

I 

4 

59 

I 

4 

30 

I 

I 

40 

I 

I 

40 

I 

I 

c 

0 

7 

0 

I 

3 

0 

I 

2 

0 

I 

2 

46 

I 

2 

0 

6 

5 

0 

I 

2 

30 

I 

4 

0 

I 

2 

40 

I 

3 

30 

I 

2 

0 

oz.  dr.  min. 

Total  quantity  excreted  in  24  nours     26  2  15 

From  10  p.m.  to  10  a.m.                 ...      10  6  10 

,,      10  a.m.  to  10  p.m.                 ...      15  4  5 


*  The  solid  matter  was  carefully  dried  until  its  weight  was  constant, 
and  on  ignition  gave  S'64  parts  of  ash. 

3 


;4    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


October  25 — 
io-ii  a.m. 
11-12  noon 
12-1 
1-2 

2-3 
3-4 
4"5 
5-6 
6-7 
7-8 
8-9 
9-10 

10-5  a.m. 
5-6 

6-7 
7-8 

8-9 
9-10 


oz. 


Beef  tea,  1  pint 


Tea,  10  oz. ;  bread,  6  oz.  ;  egg,  1 


Chicken  broth,  12  oz. 


Milk,  1  pint 


Tea,  10  oz. 


bread,  4J  oz. 


dr. 

3 

2 

1 
1 
2 
o 

1 

3 

4 

1 

3 

7 

5 

1 

o 

2 

3 
4 


min. 

30 
o 

45 
40 

o 

3° 
o 

o 

o 

o 

o 

o 

o 

3° 

3° 
o 

o 

o 


oz. 

dr. 

min. 

10  a. 

m.  to  10  p.m.  . 

...    14 

6 

25 

10  p. 

m.  to  10  a.m.  . 

...    14 

O 

O 

28 

6 

25 

October  26- 

IO-II 

a.m. 

... 

] 

2 

25 

11-12 

noon 

4 

0 

12-1 

Broth,  18  oz. 

;  pudding,  11  oz. 

0 

37 

1-2 

Bread,  1  oz. 

] 

3 

30 

2-3 

... 

] 

2 

0 

3-4 

... 

"     4 

0 

4"5 

Tea,  16  oz.  ; 

bread,  5  oz.  ;  egg, 

I          ] 

0 

35 

5-6 

... 

... 

[      4 

0 

6-7 

... 

[     0 

40 

7-8 

Milk,  1  pint 

...       C 

)     6 

50 

8-9 

... 

[     2 

15 

9-10 

. . . 

...              ... 

[     2 

0 

10-5  a.m. 

Milk,  1  pint 

...              ... 

...       * 

1     6 

0 

5-6 

[     2 

0 

6-7 

Tea,  10  oz. ; 

bread,  4^  oz. 

t     0 

0 

7-8 

... 

1     0 

0 

8-9 

... 

... 

1     5 

0 

9-10 

... 

... 

1     4 

35 

oz. 

dr. 

min. 

10  a.m.  to  10  p.m. 

...    15 

O 

52 

10  p 

.m.  to  10  a.m. 

...    14 

I 

35 

29 

2 

27 

PHYSIOLOGICAL  CONSIDERATIONS 


35 


October  27- 

oz. 

dr. 

min. 

IO-II 

a.m 

. 

... 

4 

35 

11-12 

noon 

Broth,  17  oz, 

;  pudding,  7J  oz. 

4 

0 

12-r 

...              ... 

0 

0 

1-2 

... 

0 

0 

2-3 

2 

10 

3-4 
4-5 

Tea,  17  oz.  ; 

bread,  5  oz.  ;  egg,  1 

3 
2 

33 
0 

5-6 

... 

4 

0 

6-7 

2 

0 

7-8 

Milk,  19  oz. 

... 

2 

50 

8-9 

... 

0 

0 

9-10 

...              ... 

2 

0 

10-5  a.m. 

...              ... 

7 

6 

0 

5-6 

...              ... 

0 

0 

6-7 

7-8 

Tea,   16  oz. 
10  oz. 

bread,  5J  oz.  ; 

milk, 

2 

4 

55 
0 

8-9 

... 

... 

4 

0 

9-10 

... 

... 

5 

0 

IO-II 

2 

5° 

11-12 

... 

... 

... 

4 

45 

oz. 

dr.    min. 

10 

a.m.  to  10  p.m. . 

...    15 

3       8 

10 

P. 

m.  to  10  a.m. . 

...    14 
30 

5     55 
1       3 

October  29- 

7-8  a.m. 

Tea,  10  oz. 

...                          ... 

1 

2 

45 

8-9 

Bread,  5  oz. 

...                         ... 

2 

0 

0 

9-10 

Milk,  9  oz. 

... 

5 

40 

IO-II 

... 

... 

3 

0 

11-12 

noon 

...                           ... 

1 

0 

12-1 

Chicken,  7  oz.  ;  pudding,  6  oz.     ... 

5 

11 

1-2 

... 

4 

0 

2-3 

... 

... 

4 

0 

3-4 
4-5 

Tea,  15  oz. ; 

bread,  5^-  oz.  ; 

egg,  1 

3 

2 

0 
5° 

5-6 

2 

0 

6-7 

Milk,  12  oz. 

...              ... 

0 

57 

7-8 

... 

... 

3 

30 

8-9 
9-10 

Milk,  10  oz. 

... 

3 
1 

57 
25 

10-5  a 

,m. 

Milk,  18  oz. 

8 

1 

50 

5-6 

... 

... 

1 

5° 

6-7 

7-8 
8-9 

Tea,  15  oz. ; 
Bread,  5^  oz 

bread,  5J  oz. 

0 
0 

4 

40 

35 
40 

9-10 

... 

... 

2 

0 

oz. 

dr.    min. 

10 

a.m.  to  10  p.m. . 

...    16 

2      50 

10 

P- 

m.  to  10  a.m. . 

...    14 

3     35 

30 

6     25 

36     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


October  30- 

oz. 

dr. 

min. 

IO-II 

a.m. 

...              ... 

I 

3 

30 

11-12 

noon 

Chicken,  6  oz. 

I 

3 

25 

12-1 

...              ... 

I 

2 

O 

1-2 

...              ... 

I 

3 

IO 

2-3 

0 

0 

O 

3-4 

Tea,  17  oz. ;  bread 

I 

0 

42 

4-5 

... 

I 

4 

O 

5-6 

...              ... 

I 

6 

46 

6-7 

Milk,  11  oz. 

I 

2 

O 

7-8 

... 

I 

1 

I 

8-9 

... 

I 

2 

O 

9-10 

I 

2 

40 

10-5 

Milk,  1  pint     ... 

•     7 

6 

6 

5-6 

... 

0 

7 

50 

6-7 

...              ... 

1 

2 

0 

7-8 

Tea,  15  oz. ;  bread,  ^  °2 

1 

3 

0 

8-9 

1 

5 

1 

9-10 

Milk,  12  oz. 

1 

4 

0 

oz. 

dr. 

in  in. 

10  a.m.  to  10  p.m 

14 

7 

H 

10  p 

.m.  to  10  a.m.... 

14 

3 

57 

29 

3 

11 

October  31- 

IO-II 

a.m. 

... 

1 

4 

0 

11-12 

noon 

...              ... 

1 

1 

20 

12-1 

Chicken,  6    oz. ;  puddin 

b>     I] 

02 

"  '> 

milk,  8  oz.   ... 

1 

2 

25 

1-2 

... 

1 

2 

35 

2-3 

... 

1 

3 

0 

3-4 

Tea,  10  oz.  ;  bread,  5  oz 

1 

3 

0 

4-5 

... 

1 

2 

0 

5-6 

...             ... 

1 

1 

20 

6-7 

Milk,  18  oz.      ... 

1 

3 

25 

7-8 

... 

...     0 

7 

32 

8-9 

... 

1 

0 

17 

9-10 

... 

0 

7 

50 

10-5  a.m. 

Milk,  1  pint 

...     6 

6 

0 

5-6 

... 

1 

3 

0 

6-7 

1 

4 

0 

7-8 

Tea,  15  oz. ;  bread,  5^0 

z. 

1 

3 

0 

8-9 

...        * ,o*  . . .             . 

1 

■3 
0 

50 

9-10 

M  -<vr» 

1 

3 

45 

<>/. 

dr. 

min. 

10 

a.m.  to  10  p.m — 

14 

6 

44 

.    10 

p.m.  to  10  a.m — 

*3 

7 

35 

2« 

6 

19 

PHYSIOLOGIGAL  CONSIDERATIONS 


37 


November  i- 

OZ. 

dr. 

min. 

io-ii  a.m. 

Milk,  12  oz.     ... 

O 

45 

11-12  noon 

...              ... 

I 

2 

55 

I2-I 

Chicken,  12  oz.  ;  pu 

dding 

9  oz.  ... 

5 

0 

1-2 

... 

... 

I 

2 

35 

2"3 

...              ... 

4 

0 

3-4 

Tea,  20  oz. ;  bread, 

5ioz. 

;  egg 

3 

0 

4-5 

... 

... 

I 

0 

0 

5-6 

...             ... 

3 

0 

6-7 

Milk,  15  oz.     ... 

I 

1 

10 

7-8 

... 

I 

4 

0 

8-9 

... 

0 

59 

9-10 

... 

1 

25 

10-5  a.m. 

...     7 

4 

30 

5-6 

...             ... 

1 

0 

6-7 

...             ... 

0 

3° 

7-8 

Tea,  20  oz.  ;  bread, 

6J  oz 

. 

0 

7 

0 

8-9 

... 

.  • 

5 

10 

9-10 

... 

... 

1 

4 

0 

oz. 

dr.    min. 

10  a.m.  to  10  p.m — 

15 

4     49 

10  p. 

m.  to  10  a.m — 

... 

J3 

6     10 

29 

2     59 

November  2 



IO-II 

a.m. 

Milk,  20  oz. 

. . 

1 

5 

10 

11-12 

noon 

Chicken  and  bread, 

6  oz. 

;  pu 

iding, 

II  oz. 

. 

1 

2 

40 

12-1 

... 

I 

1 

0 

1-2 

...             ... 

I 

6 

0 

2-3 

...             ... 

... 

I 

2 

19 

3-4 

... 

.• 

. 

... 

I 

1 

2 

4-5 

Tea,  9  oz. 

•  • 

I 

4 

0 

5-6 

. 

I 

4 

0 

6-7 

Milk,  15  oz.     .. 

. 

I 

2 

3 

7-8 

... 

. 

0 

5 

2 

8-9 

... 

•  • 

. 

I 

0 

40 

9-10 

... 

.. 

. 

•  • 

0 

7 

35 

10-5  a.m 

...             .  • 

. 

6 

4 

0 

5-6 

...             . . 

. 

1 

1 

10 

6-7 

... 

. 

.     0 

7 

39 

7-8 

. 

•  • 

1 

0 

35 

8-9 

... 

.. 

1 

4 

17 

9-10 

... 

•• 

• 

1 

4 

50 

oz. 

dr.    min. 

10  a.m.  to  ic  p.m.  ... 

15 

I      31 

10  p 

.m.  to  10  a.m 

12 

6      31 

2S 

O          2 

38     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


November  3 

oz. 

dr. 

min. 

IO-II 

a.m. 

Milk,  9  oz. 

I 

O 

11-12 

noon 

...              ...              ... 

I 

15 

12-1 

Chicken,  6^  oz. ;  pudding,  6^  oz. 

I 

J5 

1-2 

... 

7 

5° 

2-3 

0 

0 

3-4 

Tea,  15  oz. ;  bread,  6  oz.  ;  egg,  1 

1 

30 

4-5 

.. 

4 

0 

5-6 

... 

4 

0 

6-7 

Milk,  9  oz. 

O 

6 

0 

7-8 

Euonymin,  gr.  jss.,  at  7  p.m. 

3 

10 

8-9 

... 

2 

0 

9-10 

... 

1 

32 

10-5  a.m. 

... 

8 

1 

0 

5-6 

1 

40 

6-7 

... 

1 

40 

7-8 

Tea,  11  oz. ;  bread,  4  oz. 

0 

0 

8-9 

...             ...             ... 

6 

0 

9-10 

4 

0 

oz.    dr. 

min. 

10  a.m.  to  10  p.m.  ...             ...     15     1 

32 

10  p. 

m.  to  10  a.m.  ...              ...      14     6 

20 

29     7 

52 

November  4 

IO-II 

a.m. 

Milk,  9  oz. 

2 

0 

11-12 

noon 

1 

0 

12-1 

Chicken,   6   oz. ;    pudding,    9    02 
milk,  9  oz.     ... 

f ' 

2 

0 

1-2 

5 

0 

2-3 

4 

45 

3-4 

Bread,  3  oz. ;  tea,  16  oz. ;  egg,  1 

0 

6 

0 

4-5 

... 

1 

0 

5-6 

4 

0 

6-7 

...             ...             ... 

0 

0 

7-8 

2 

0 

8-9 

...             ...             ... 

1 

0 

9-10 

Euonymin,  gr.  iii.,  at  10.30  p.m. 

0 

15 

10-5  a.m. 

Milk,  1  pint     ... 

7 

0 

10 

5-6 

0 

36 

6-7 

3 

5 

7-8 

Tea,  10  oz. ;  bread,  6  oz. 

0 

45 

8-9 

...              ...              ... 

0 

0 

9-10 

Milk,  9  oz. 

0 

0 

oz.     dr. 

min. 

10  a.m.  to  10  p.m.  ...              ...      14     5 

O 

10  p 

m.  to  10  a.m.  ...              ...      124 

36 

27     1 

36 

PHYSIOLOGICAL  CONSIDERATIONS 


39 


November  5 

— 

oz. 

dr. 

min. 

IO-II 

a.m. 

... 

2 

O 

11-12 

noon 

...             ...             ... 

O 

40 

12-1 

Chicken  and  potato,  8  oz. ;  pudding 

4 

O 

1-2 

... 

2 

25 

2-3 

...              ...              ... 

I 

40 

3-4 

Tea,  16  oz. ;  bread,  6  oz.  ;  egg,  1 

I 

J5 

4-5 

... 

3 

0 

56 

... 

2 

50 

6-7 

Milk,  10  oz. 

1 

0 

7-8 

... 

0 

25 

8-9 

... 

O 

7 

0 

9-10 

... 

6 

55 

10-5  a 

.m. 

Milk,  1  pint     ... 

7 

0 

0 

5-6 

... 

0 

0 

6-7 

...             ...             ... 

0 

7 

0 

7-8 

Tea,  16  oz. ;  bread,  4J  oz. 

3 

10 

8-9 

2 

0 

9-10 

... 

4 

0 

oz. 

dr. 

min 

10  a.m.  to  10  p.m.  ...              ...      15 

I 

10 

10  p. 

m.  to  10  a.m.  ...              ...      13 

0 

IO 

28 

I 

20 

November  6 

— 

IO-II 

a.m. 

Milk,  8  oz. 

.  # 

1 

4 

20 

11-12 

noon 

Chicken  and  potato,  7  oz. ;  pudding, 

8oz. 

1 

2 

25 

12-1 

... 

1 

4 

0 

1-2 

... 

1 

1 

50 

2-3 

1 

1 

0 

3-4 

Tea,  10  oz. ;  bread,  6  oz. 

1 

1 

10 

4-5 

1 

0 

0 

5-6 

...             ...              ... 

1 

3 

0 

6-7 

Milk,  10  oz. 

1 

2 

0 

7-8 

1 

3 

0 

8-9 

... 

1 

0 

0 

9-10 

...             ...             ... 

1 

0 

5 

10-5  a.m. 

Milk,  1  pint 

6 

1 

5 

5-6 

... 

0 

1 

30 

6-7 

0 

3 

0 

7-8 

Tea,  11  oz.  ;  bread,  4J  oz. 

1 

1 

30 

8-9 

1 

5 

0 

9-10 

Milk,  8oz. 

1 

4 

0 

10  a.m.  to  10  p.m.  .. 
10  p.m.  to  10  a.m.  . 


oz. 

14 
11 


dr. 
6 
o 


min, 
50 

5 


25  6  55 


40    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 


November  7 — 

oz. 

dr. 

min 

IO-II 

a.m. 

I 

2 

0 

11-12 

noon     Chicken  and  potato,  8  oz. 

I 

O 

O 

I2-I 

...              ... 

I 

2 

O 

1-2 

...              ...              ... 

I 

2 

O 

2-3 

...              ...              ... 

. . . 

I 

2 

20 

3-4 

Tea,  16  oz. ;  bread,  6  oz. ;  egg,  i 

I 

2 

0 

4-5 

... 

I 

2 

IO 

5-6 
6-7 
7-8 

Milk,  17  oz.     ... 
Calomel,  gr.  v. 

... 

I 
I 
I 

3 
2 

O 

10 

40 

O 

8-9 

...             ...             ... 

I 

O 

0 

g-io 

... 

0 

6 

0 

10-5  a 

.m. 

... 

... 

7 

6 

3° 

5-6 

...             ...             ... 

i 

0 

0 

6-7 
7-8 

Tea,  16  oz. ;  bread,  4I  oz. 

0 
0 

6 

7 

35 
0 

8-g 

...             ...             ... 

1 

2 

0 

9-10 

Milk,  10  oz.     ... 

ruin. 

1 

3 

0 

oz. 

dr. 

10 

a.m.  to  10  p.m. ...              ...      14 

O 

20 

10 
At 

p.m.  to  10  a.m. ...              ...      13 

1 

5 

27 
7  p.m.,  calomel,  gr.  v. 

I 

25 

10 

hours  before         ...              ...      12 

6 

20 

10 

hours  after          ...              ...      10 

4 

3° 

Corresponding  10  hours  after 

on  previous  day              ...       9 

4 

10 

November  8 

io-ii  a.m 

.                 ...              ...              ... 

1 

2 

40 

I  I-I2 

noon     Chicken  and  potato,  8  oz. ; 

milk, 

8  oz. ;  gravy,  1  oz. 

0 

0 

I  2- 1 

2 

0 

1-2 

... 

1 

3^ 

2-3 
3-4 

Tea,  19  oz. ;  bread,  i\  oz.; 

pcrcr 

1 

4 
1 

0 
25 

4-5 

... 

.. 

1 

55 

5-6 

... 

3 

20 

6-7 

2 

0 

7-8 

...              ...              ... 

4 

0 

8-g 

... 

1 

0 

9-10 

...              ...              ... 

0 

20 

10-5  a.m. 

Milk,  16  oz.      ... 

..     ( 

6 

0 

oz. 

dr. 

min. 

10 

a.m.  to  10  p.m. ...              ...      15 

0 

10 

10 

p.m.  to  10  a.m.  ...              ...      12 

6 

25 

27 

6 

35 

PHYSIOLOGICAL  CONSIDERATIONS 


4r 


mb 

?y  9 — 

5 

•6  a  m 

6 

7 

7 

•8 

8- 

•9 

9 

■io 

IO- 

ii 

1 1 

12 

12- 

I 

I- 

2 

2- 

3 

3-4 

4-5 

5 

■6 

6 

■7 

7 

•8 

8- 

9 

Tea,  19  oz.;  bread,  \\  oz 

Milk,  10  oz.     ... 

Chicken  and  potato,  8  oz. 
8  oz. 

Tea,  12  oz.;  bread,  \\  oz 


pudding 


oz.    dr. 

I 
2 
I 

3 

7 
1 

1 
1 
2 

1 

4 

5 
1 

1 

o 

2 


min. 

50 
o 

55 
40 

o 

o 


45 
o 

35 
o 

o 

21 


oz. 

dr. 

min. 

9  a.m 

.  to  9  p.m. 

J3 

4 

5 

November  12— 

9-12 

noon 

Milk,  1  pint     ... 

•     3 

4 

0 

12-1 

Meat,  etc.,  16  oz.;  water, 

10 

oz. 

1 

3 

2 

1-2 

...              ... 

1 

2 

2 

2-3 
3-4 

Tea,  20  oz.;  bread,  2  oz. 

1 
1 

3 
4 

1 
2 

4-5 
5-6 

... 

1 
1 

6 
6 

3 

2 

6-7 

... 

1 

4 

1 

7-8 

... 

1 

4 

2 

8-9 

... 

1 

2 

1 

oz. 

dr. 

min. 

9  a.m 

.  to  9  p.m. 

16 

6 

16 

November  1 

3— 

5-6  a 

.m. 

...              ... 

I 

3 

0 

6-7 

... 

I 

0 

10 

7-8 

8-9 

Tea,  1  pint ;  bread,  4  oz. 

O 
I 

7 
4 

5 

4 

9-10 

IC-II 

Milk,  10  oz. 

I 

I 

4 
1 

3 
1 

1 1-12 

Tinct.  rhei,  3SS. 

O 

6 

5 

12-1 

Meat,  etc.,  10  oz. ;  water, 

10 

OZ. 

I 

2 

1 

1-2 

...              ... 

I 

0 

2 

2-3 

...              ... 

I 

0 

0 

3-4 
4-5 
5-6 

Tea,  1  pint ;  bread,  1  oz. 

I 
I 

I 

6 
6 
0 

3 

8 

8 

6-7 

m  •   •                                        •  •   ■                                         •  • 

I 

2 

6 

7-8 

Milk,  15  oz.;  bread,  2  oz. 

I 

0 

0 

8-9 

... 

I 

1 

8 

Q-TO 

... 

I 

2 

0 

42     DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

November  13 — continued  : 


5  a.m.  to  11  a.m.    ... 
At  11,  tinct.  rhei,  5SS. 
11  a.m.  to  5  p.m.    ... 
g  a.m.  to  9  p.m. 


(Cf.  November  9  and  12,  and  Novem- 
ber 14  and  15.) 
10  a.m. to  10  p.m.  ...  ...  ...   14     2     42 

10  p.m.  to  10  a.m.  not  measured. 


oz. 

dr. 

niin 

7 

3 

23 

7 

4 

19 

14 

4 

45 

November 

14— 

6 

a.m.  to  6  p.m.    ... 

...    16 

6 

37 

9 
11 

a.m.  to  9  p.m.   ... 
a.m.  to  5  p.m.    ... 

...   17 

7 

45 

...     9 

6 

11 

12 

a.m.  to  6  p.m.    ... 

...    10 

2 

10 

November  1 

5— 

6-7  a.m. 

...              ... 

1 

2 

0 

7-8 

...     0 

6 

4 

8-9 

Tea,  20  oz.;  bread,  2  oz. 

0 

8 

9-10 

...              ... 

0 

S 

10- 1 1 

Milk,  10  oz. 

6 

10 

11-12 

Tinct.  rhei,  51.   ... 

0 

6 

12-1 

Meat,  etc.,  12  oz.;  water,  ] 

[0  oz. 

2 

4 

1-2 

... 

2 

0 

2-3 

... 

4 

2 

3-4 

...              ... 

2 

8 

4-5 

Tea,  20  oz. ;  bread,  ij  oz. 

0 

10 

5-6 

...              ... 

1 

0 

6-7 

. . . 

7 

S 

7-8 

Milk,  15  oz.;  bread,  1  oz. 

5 

4 

8-9 

... 

0 

5 

9-10 

...              ... 

1 

0 

At  11.30,  tinct.  rhei,  51. 

oz. 

dr. 

min. 

6  a.m.  to  12 

6 

6 

33 

12  to  6  p.m. 

7 

3 

24 

9  a.m.  to  9  p.m. 

15 

5 

57 

PHYSIOLOGICAL  CONSIDERATIONS 


43 


November  16 — 
6-7  a.m. 
7-8 
8-9 
9-10 

IO-II 

11-12 
12-1 
1-2 

2-3 
3-4 
4-5 
5-6 

6-7 

7-8 

8-9 


Tea,  20  oz. ;  bread,  6  oz 
Milk,  10  oz. 
Meat,  16  oz.     ... 
Water,  10  oz.  ... 
Tea,  20  oz. ;  bread,  3  oz 

Milk,  15  oz.;  bread,  2  oz 


oz. 

dr. 

min 

I 

2 

O 

I 

2 

8 

I 

4 

6 

I 

3 

2 

0 

0 

O 

2 

7 

3 

I 

2 

5 

I 

4 

3 

I 

4 

7 

I 

1 

5 

I 

4 

3 

I 

5 

4 

I 

0 

3 

O 

7 

5 

I 

1 

7 

6  a.m 

.  to  6  p.m. 

oz. 

16 

dr. 
6 

min 

46 

November  j 

7— 

7-8  am. 
8-9 

Tea,  20  oz. ;  bread,  7  oz. 

1 
I 

2 
6 

4 
1 

9-10 

IO-II 

11-12 
12-1 

Milk,  10  oz. 
Euonymin,  gr.  iv. 
Meat,  etc.,  16  oz. ;  water, 

10 

OZ. 

I 
I 
I 
I 

2 
2 

3 

2 

1 

3 

4 
5 

1-2 

...              ... 

1 

2 

0 

2-3 
3-4 
4-5 

Tea,  20  oz. ;  bread,  2  oz 

1 

1 
1 

3 

2 

3 

0 

3 
5 

5-6 
6-7 
7-8 

Milk,  15  oz.;  bread,  2  oz. 

I 
2 
I 

4 
2 

1 

7 
0 
1 

8-9 
9-10 

... 

I 
I 

0 
3 

3 

0 

oz.    dr.  min. 

7  a.m.  to  11  a.m.    ...             ...       5     4  9 

At  11.30,  euonymin,  gr.  iv. 

12  to  4  p.m.             ...              ...       51  8 

10  a.m.  to  10  p.m.                  ...      16     3  31 


44 


DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


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PHYSIOLOGICAL  CONSIDERATIONS 


45 


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46    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


Hourly  Secretion  of  Bile  for  Forty-eight  Consecutive 

Hours.     Normal. 


April  10 — 

oz. 

dr. 

min. 

April  11  (cont.) — 

oz. 

dr. 

min. 

11-12  noon. 

5 

30 

1 1- 12  noon. 

I 

5 

5 

12-1  p.m.    . 

5 

20 

12-1.30  p.rr 

2 

4 

30 

1-2 

I 

5 

25 

1.30-2 

I 

1 

5 

2-3 

4 

15 

2-3 

I 

4 

O 

3-4 

5 

3° 

3-4 

I 

7 

IO 

4-5 

3 

0 

4-5 

2 

0 

0 

5-6 

3 

10 

5-6 

..       2 

0 

0 

6-7 

0 

7 

0 

6-7 

I 

6 

0 

7-8 

0 

0 

7-8 

I 

4 

0 

8-9 

I 

1 

0 

8-9 

I 

5 

IO 

9-10 

I 

2 

0 

9-10 

I 

3 

IO 

IO-II 

0 

35 

IO-II 

I 

2 

0 

11-12 

1 

10 

11-12 

I 

5 

20 

12-1  a.m. 

4 

0 

1 2- 1  a.m. 

O 

6 

45 

April  11 — 

April  12 — 

1-2 

I 

2 

0 

1-2  a.m 

I 

2 

J5 

2-3 

I 

1 

30 

2-3 

O 

7 

0 

3-4 

I 

2 

0 

3-4 

I 

4 

55 

4-5 

I 

0 

20 

4-5 

I 

4 

45 

5-6 

I 

1 

15 

5-6 

2 

0 

35 

6-7 

0 

6 

0 

6-7 

I 

5 

10 

7-8 

I 

0 

0 

7-8 

2 

0 

0 

8-9 

I 

3 

30 

8-9 

2 

1 

3° 

9-10 

I 

4 

0 

9-10 

I 

6 

0 

IO-I  1 

I 

3 

25 

IO-II 

I 

6 

0 

3^ 

7 

55 

39 

4 

25 

PHYSIOLOGICAL  CONSIDERATIONS 


47 


Bile  Flow 

FOR 

Tw 

ENTY- 

•OUR 

Hours,  without 

I 

RIDIN. 

April  13 — 

oz. 

dr. 

min. 

10- 1 1  a.m. . 

2 

O 

O 

11-12 

2 

O 

O 

Noon  1 2- 1  p. 

m. 

2 

I 

*5 

1-2 

2 

O 

O 

2-3 

I 

6 

O 

3-4 

2 

2 

O 

4-5 

2 

0 

O 

5-6 

I 

6 

0 

6-7 

I 

5 

0 

7-8 

I 

0 

50 

8-9 

I 

4 

0 

9-10 

I 

4 

0 

10- 1 1 

11-12 


April  14- 


12-1  a.m. 
1-2 
2-3 
3-4 
4-5 
5-6 
6-7 
7-8 
8-9 
9-10  a.m. 

Total 


0     6     35 

o     6     45 


o 

5 
o 

o 

35 

15 
o 

10 

o 

o 


Flow  Hourly  Before. 


April  16 —  oz.    dr. 


April  15- 


oz.    dr.    min. 
O      I      15 

I20 


April  16- 
o 
o 
o 
o 
1 
1 
1 
1 
1 
1 


34     7     30 


30 

35 
o 

o 
15 
35 
J5 

o 

30 
o 


o 
o 

2 

4 

2 
O 

7 
o 

1 

o 

7 
o 


12     6 


min. 

O 

O 

O 

O 
30 

o 
o 
o 
o 
o 
o 
o 


20     7     30 


;>:> 


12 


55 


33     6     2: 


10  a.m.,  iridin,  gr.  iv. 


CHAPTER  III 

INJURIES  TO  THE  BILE  PASSAGES 

Injuries  to  the  bile  passages  are,  as  might  be  expected, 
much  less  common  than  injuries  to  the  liver,  and  they  are 
apt  to  be  confounded  with  the  latter,  though  in  reality  they 
present  many  points  of  difference. 

They  may  be  caused  by  a  stab  or  gunshot  wound,  or  by 
a  violent  blow  or  severe  compression  in  the  region  of  the 
liver.  These  injuries  appear  to  be  more  common  in  persons 
who  have  already  suffered  from  biliary  calculi  or  from  inflam- 
matory lesions  of  the  gall-bladder  or  ducts.  Such  cases  have 
been  reported  by  Terrier,  Hofmann,  Salmuth,  and  others. 

In  a  case  reported  by  Janeway,  rupture  of  the  gall-bladder 
was  attributed  to  traction  caused  by  old  and  firm  adhesions, 
the  result  of  previous  gall-stones. 

The  fundus  of  the  gall-bladder,  the  most  exposed  portion 
of  the  bile-excreting  apparatus,  is  the  part  most  frequently 
injured,  both  in  penetrating  wounds  and  in  subcutaneous 
injuries. 

Frequently  in  the  case  of  penetrating  wounds  the  neigh- 
bouring organs  are  injured,  e.g. — the  liver,  stomach,  or  colon. 

Ogston  and  Kilgour  reported  two  cases  in  which  the  gall- 
bladder, with  the  attached  liver  tissue,  was  found  completely 
separated  from  the  rest  of  the  liver. 

Courvoisier  collected  forty-eight  cases,  of  which  three  were 
subcutaneous  ruptures  and  fourteen  penetrating  wounds  of 
the  bile  passages. 

Specimen  No.  2,267  m  St.  Bartholomew's  Museum  shows 
a  laceration  J  inch  long  in  a  gall-bladder  previously  dilated, 
as  the  result  of  a  gall-stone  lodging  at  the  entrance  of  the 

[48] 


PLATE   II 


Fig.    17. — Laceration    of    Gall-bladder. 
(No.  2,267,  St.  Bartholomew's  Museum.) 


Fig.     iS. — Rupture     of    Gall-bladder. 
(No.  2,26s,  St.  Bartholomew's  Museum.) 


To  face  p.  48.] 


INJURIES  TO  THE  BILE  PASSAGES  49 

cystic  duct  (Fig.  17).  The  specimen  is  from  a  man  of  fifty 
who  was  kicked  when  stooping.  No.  2,268  shows  a  rupture 
of  the  fundus  of  the  gall-bladder  caused  by  a  fall  on  a  piece  of 
timber.  Bile  escaped  into  the  peritoneum,  and  death  followed 
from  peritonitis  after  five  weeks  (Fig.  18). 

No.  2,268a  shows  a  perforating  wound  of  the  gall-bladder 
from  a  boy  of  fifteen  who  fell  from  a  load  of  straw  on  to 
a  pitchfork.  Death  occurred  after  five  days  from  extravasa- 
tion of  bile  and  peritonitis  (Fig.  19). 

No.  1,388  in  Guy's  Museum  is  a  case  of  lacerated  gall- 
bladder from  a  man  of  twenty-nine  who  was  kicked  in 
the  abdomen  and  died  on  the  seventeenth  day  from  peri- 
tonitis. The  laceration  in  the  gall-bladder  measures  §  inch 
(Fig.  20). 

In  all  cases  where  the  history  is  appended,  the  fact  of  the 
long  survival  after  so  serious  an  accident  is  notable,  and  the 
lesson  is  manifest  that  operation  would  in  each  case  have 
given  good  hopes  of  success. 

As  a  result  of  a  wound  or  rupture  of  any  part  of  the  biliary 
secreting  apparatus,  extravasation  of  bile  occurs  into  the 
peritoneum.  As  a  rule  the  bile  occupies  the  right  half  of  the 
abdomen,  extending  down  to  the  iliac  fossa.  It  is  confined 
to  this  portion  of  the  abdomen  by  the  insertion  of  the 
mesentery,  but  occasionally  it  extends  to  the  pelvis,  or  even 
into  the  left  loin.  After  a  certain  time  the  collection  of  bile 
becomes  encapsuled  by  the  formation  of  a  false  membrane 
on  the  surrounding  viscera.  This  false  membrane  frequently 
seals  the  opening  in  the  gall-bladder  or  ducts,  preventing  the 
further  escape  of  bile,  and  rendering  it  difficult  at  an  operation 
to  detect  the  actual  situation  of  the  injury.  The  symptoms 
observed  in  the  majority  of  cases  are  more  or  less  profound 
shock,  followed  by  reaction,  rise  of  temperature,  and  pain  in 
the  right  hypochondrium,  with  the  appearance  of  dulness  on 
the  right  side  of  the  abdomen.  The  most  characteristic  sign 
of  injury  to  the  bile  passages  is  the  appearance  of  jaundice 
after  some  days,  owing  to  the  reabsorption  of  the  extravasated 
bile.  This  is  characteristic,  and  does  not  occur  to  the  same 
extent  in  injuries  of  the  liver. 

If  the  bile  is  aseptic  there  may  be  no  peritonitis,  and  in 

4 


50    DISEASES  OF  THE  GALL-BLADDER  AXD  BILE -DUCTS 

some  cases  spontaneous  recovery  has  undoubtedly  occurred 
(Martel,  Bull,  de  la  S  octet e  de  Chirurgie,  1882). 

Recovery  has  also  occurred  after  the  spontaneous  formation 
of  a  biliary  fistula  (Cauchois,  Union  Medicate,  1872). 

As  a  rule,  even  in  cases  in  which  the  bile  is  aseptic, 
gradual  emaciation  occurs,  ending  in  death,  probably  owing 
to  the  absorption  of  some  toxic  matter  from  the  extravasated 
bile. 

Septic  peritonitis  may  occur  at  any  time,  as  the  bile  may 
be  already  septic  from  previous  gall-bladder  disease,  or 
infection  may  arise  by  proximity  to  the  bowel,  or  after 
exploration,  aspiration,  or  laparotomy.  Courvoisier  collected 
thirty-three  cases,  in  eighteen  of  which  the  extravasated 
bile  had  been  removed  by  aspiration.  In  eleven  of  these 
recovery  followed.  He  advocated  repeated  aspiration  before 
resort  to  laparotomy.  Occasionally  a  single  aspiration  has 
been  successful ;  more  usually  multiple  aspirations  are  re- 
quired before  recovery  ensues. 

Terrier  and  Auvray  {Chirurgie  de  Foie)  collected  seventeen 
cases  in  which  aspiration  (in  most  cases  repeated)  had  been 
performed.     Of  these,  ten  recovered  and  seven  died. 

Laparotomy  may  be  performed  as  a  primary  or  a  secondary 
operation.  The  former  will  probably  be  restricted  to  cases 
of  penetrating  wounds,  while  the  latter  will  be  performed  in 
cases  of  subcutaneous  injury.  Kehr  (Centralb.  f.  Chirurg., 
1892)  reports  a  case  of  a  man,  aged  thirty,  suffering  from 
a  bullet  wound  of  the  gall-bladder.  Immediate  laparotomy, 
with  suture  of  the  opening,  was  followed  by  recovery.  Dalton 
(Transactions  of  Med.  Assoc,  of  Missouri,  May,  1892)  performed 
laparotomy  for  a  knife  wound  of  the  abdomen  resulting 
in  prolapse  of  the  intestine.  The  bowel  was  replaced,  and 
both  the  fundus  of  the  gall-bladder  and  the  stomach  were 
found  to  be  wounded.  The  wounds  were  sutured  and  the 
abdomen  drained  with  gauze,  recovery  ensuing. 

Walton  (Belgique  Medicate,  1897)  sutured  a  small  wound 
in  the  fundus  of  the  gall-bladder,  but  the  patient  died  of 
peritonitis.  The  wound  was  found  at  the  autopsy  to  be 
firmly  closed.  Secondary  laparotomy  will  usually  be  per- 
formed   in    cases   of    subcutaneous    rupture,    owing   to   the 


INJURIES  TO  THE  BILE  PASSAGES  51 

difficulties  in  diagnosis  until  jaundice  appears.  In  many 
cases  it  will  be  impossible  to  detect  the  wound  owing  to  the 
formation  of  false  membrane.  In  these  cases  the  bile  should 
be  washed  out  with  saline  solution  and  the  abdomen  drained. 

If  a  small  wound  is  found  in  the  gall-bladder,  it  may  be 
sutured   or  the  gall-bladder    may   be    drained   through   the 
opening.      If  the  gall-bladder  is  extensively  lacerated,  or  if 
the  cystic  duct  is  injured,  cholecystectomy  should  be  per- 
formed. 

Dixon  (Annals  of  Surgery,  April,  1887),  during  the  course 
of  a  secondary  laparotomy,  found  the  gall-bladder  so  ex- 
tensively ruptured  that  cholecystectomy  was  necessary.  At 
the  autopsy,  calculi  were  found  impacted  in  the  common 
bile-duct. 

The  following  case  {Lancet,  May  21,  1898)  of  drainage  of 
the  gall-bladder,  apparently  thirty  days  after  rupture,  by 
Dr.  Martin  of  Blackburn,  is  of  extreme  interest,  and  is  there- 
fore given  at  length  : 

A  boy,  aged  nine  years,  was  admitted  to  the  Blackburn 
and  East  Lancashire  Infirmary  on  November  26,  1897. 
Four  days  before  admission  his  abdomen  had  been  run  over 
by  a  cart  weighing  15  cwt.  After  the  injury  he  was  carried, 
or  rather  dragged,  a  quarter  of  a  mile  to  his  home.  The 
medical  man  who  then  saw  him  reported  that  '  he  was  suffer- 
ing from  shock  and  pain  in  the  right  side  of  his  abdomen, 
not  specially  confined  to  the  liver.'  Next  day  his  symptoms 
were  distinct  abdominal  swelling,  slight  discoloration  over 
the  region  of  the  gall-bladder,  and  a  temperature  of  1010  F.  ; 
there  was  no  vomiting.  On  the  24th  there  was  retention  of 
urine,  and  his  '  bowels  were  moved,  the  motion  giving  marked 
evidence  of  blood.'  On  admission  to  the  infirmary  the  boy 
looked  very  ill,  and  complained  of  pain  in  the  abdomen, 
which  was  slightly  distended,  but  not  very  tender  to  the 
touch.  Nothing  else  was  made  out  by  physical  examination 
of  the  abdomen.  His  pulse  was  100,  and  his  temperature 
was  980  F.  His  tongue  was  furred  ;  there  was  no  sickness. 
Nothing  in  the  way  of  local  treatment  seemed  indicated,  and 
milk  with  lime-water  was  the  only  food  given.  At  10  p.m. 
the  temperature  rose  to  ioi*8°  F.    Once  during  the  afternoon 

4—2 


52     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

there  was  vomiting  of  curdled  milk.  Next  morning  the 
abdominal  tenderness  had  almost  disappeared,  and  the  boy 
looked  much  better.  He  complained  of  being  hungry. 
From  this  time  till  December  2,  (six  days),  when  he  was  sent 
home,  improvement  was  very  rapid  ;  in  fact,  two  days  before 
discharge  he  was  found  running  about  the  ward  during  the 
nurse's  absence  for  a  short  time.  He  was  discharged  as 
being  '  well,'  and  was  taken  home  to  Accrington  by  an 
uncle,  who  carried  him  most  of  the  way.  The  uncle  states 
that  in  the  train  the  boy  complained  of  feeling  ill,  and  when 
he  was  seen  the  same  evening  by  his  former  medical 
attendant,  he  was  '  complaining  of  pain  in  the  abdomen  and 
vomiting  bilious  fluid.'  The  abdomen  had  become  distended 
again.  He  remained  at  home  for  twenty-one  days,  and 
during  this  time  the  stools  were  clay-coloured.  He  was  sick 
occasionally  during  this  time,  and  the  abdomen  remained 
swollen.  On  admission  to  the  infirmary  for  the  second  time 
a  great  change  was  evident  in  the  boy.  He  had  lost  a  great 
deal  of  flesh  ;  the  abdomen  was  full  of  fluid  of  some  kind,  but 
was  not  tender.  The  temperature  was  980  F.,  and  the  pulse 
was  no.  The  tongue  was  furred;  there  was  no  jaundice, 
neither  was  bile  present  in  the  urine ;  the  stools  were  clay- 
coloured.  The  temperature  remained  normal  during  the 
second  twenty-four  hours  after  admission.  On  the  third  day 
the  abdomen  was  opened  in  the  middle  line  above  the 
umbilicus  by  an  incision  2  inches  long.  Nearly  5  pints 
of  fluid  escaped.  This  fluid,  which  was  deeply  bile-stained, 
was  in  the  general  peritoneal  cavity,  and  not  in  any  way 
limited  by  adhesions.  The  coils  of  intestine  in  the  neigh- 
bourhood of  the  liver  were  matted  together  with  lymph. 
The  gall-bladder  was  empty,  and  was  thought  on  digital 
exploration,  to  be  adherent  to  the  parietal  peritoneum.  A 
drainage-tube  was  left  in  the  wound,  and  a  bulky  dressing 
was  applied.  The  boy  bore  the  operation  well,  and  there 
was  no  rise  of  temperature  afterwards.  The  dressing  was 
removed  on  the  second  day,  and  found  to  be  soaked  with 
bile-stained  fluid.  The  boy's  general  condition  had  improved, 
his  tongue  being  moist  and  his  pulse  better.  The  after- 
history  is  only  remarkable  for  the  rapidity  of  recovery.     The 


INJURIES  TO  THE  BILE  PASSAGES  53 

temperature  never  reached  ioo°  F.,  the  discharge  became  less, 
each  day,  and  the  tube  was  discontinued  on  the  seventh  day. 
The  total  quantity  of  fluid  absorbed  by  the  dressing  would 
almost  equal  the  first  amount  removed.  Bile  was  noticed 
for  the  first  time  in  the  faeces  on  the  third  day  after  the 
operation.  The  urine  was  examined  each  day  for  bile,  but  it 
was  never  detected.  The  daily  average  quantity  of  urine  was 
only  20  ounces.  The  patient  was  discharged  on  January  1, 
1898,  and  when  seen  on  March  21  was  quite  well. 

If  a  wound  of  the  hepatic  duct  be  discovered,  it  may  be 
possible  to  close  the  opening  by  sutures.  In  most  cases 
reliance  must  be  placed  on  drainage. 

The  following  case  is  an  example  of  injury  to  the  hepatic 
duct  : 

A.  M.,  aged  twenty-five,  was  admitted  to  the  infirmary  on 
May  12, 1902,  having  been  crushed  between  the  buffers  of  two 
trucks.  He  had  rallied  from  the  shock,  and  on  admission  his 
pulse  was  70  and  temperature  970  F.  He  had  vomited  several 
times,  and  complained  of  pain  in  the  left  hypochondrium.  On 
examination,  no  distension  of  the  abdomen,  which  moved 
freely  with  respiration.  Some  tenderness  over  caecum  and 
ascending  colon.  Liver  dulness  present.  Patient  passed 
urine  soon  after  admission,  which  was  free  from  blood. 

May  13. — Abdomen  not  moving  so  freely.  Pain  over 
caecum  and  ascending  colon,  with  tenderness.  Liver  dulness 
present.  No  more  vomiting.  Pulse  80,  temperature 
ioo°  F.  In  the  evening  dulness  in  the  right  hypochondrium, 
extending  down  into  the  loin  and  up  to  the  chest. 

May  14. — Area  of  dulness  slightly  increased. 

May  15. — Patient  jaundiced;  bile  in  urine;  pulse  So, 
temperature  ioo°  F.  Patient  seemed  to  improve  up  to 
May  21,  when  the  abdomen  became  more  distended  and 
vomiting  commenced.      Temperature  1010  F.,  pulse  100. 

May  22. — Pulse-rate  rising  ;  temperature  subnormal  ;  dis- 
tension and  dulness  increasing  ;  vomiting  continuing. 

Operation. — Vertical  incision  made   over  the  gall-bladder, 

and  5  pints  of  fluid  (bile  and  pus)  evacuated  from  peritoneum. 

The  gall-bladder  was  adherent,   but  not  ruptured.     As  the 

patient's  condition  would  not  permit  much  exploration,  the 


54    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

abdomen  was  washed  out  with  saline  solution,  the  wounds 
were  closed,  a  tube  inserted  into  the  pelvis,  another  into 
the  right  kidney  pouch,  and  another  down  to  the  gall- 
bladder. 

After  operation  the  vomiting  and  distension  continued,  and 
the  patient  died  from  peritonitis  on  May  26. 

At  the  autopsy  diffuse  peritonitis  was  found,  with  rupture 
of  the  hepatic  duct. 

Mr.  Battle  has  reported*  the  case  of  a  boy,  aged  six  months, 
who  had  been  run  over  by  a  cab.  At  first  there  were  no 
definite  signs  of  visceral  injury  ;  by  the  seventh  day,  how- 
ever, he  was  deeply  jaundiced,  with  symptoms  of  acute 
peritonitis. 

Abdominal  section  was  done  on  the  eighth  day,  and  a 
large  quantity  of  almost  pure  bile  evacuated,  but  no  injury 
to  the  bile  apparatus  could  be  detected.  He  died  on  the 
ninth  day,  and  post-mortem  the  liver  and  gall-bladder 
were  found  intact,  but  the  common  bile-duct  was  found 
completely  torn  through. 

This  is  apparently  the  first  recorded  case  of  an  operation 
for  such  an  accident;  but  in  Guy's  Museum,  No.  1,417,  is  a 
specimen  from  a  case  of  Mr.  Bryant's,  where  there  is  a 
laceration  of  the  hepatic  duct  near  its  origin,  and  in  which 
death  occurred  from  peritonitis  after  a  week's  illness,  2  pints 
of  bile-stained  fluid  mixed  with  blood-clots  being  found  in 
the  peritoneal  cavity. 

In  the  Lancet  for  March  12,  1898,  Mr.  Whipple  records  a 
case  of  cyst  in  connection  with  the  liver  apparently  due  to 
the  rupture  of  a  hepatic  duct. 

The  patient  was  a  boy,  aged  sixteen,  who  a  month  before 
coming  under  treatment  had  been  kicked  in  the  abdomen  by 
a  horse.  Immediately  after  the  injury  he  had  a  good  deal 
of  pain,  but  not  much  subsequently.  He  vomited  on  the 
following  day,  but  no  record  of  the  character  of  the  vomited 
matter  was  kept.  A  week  later  there  was  observed  an 
abdominal  swelling,  which  gradually  increased  in  size.  On 
examination,  there  was  found  a  large  tumour  about  8  inches 
in  diameter  occupying  the  epigastric,  and  parts  of  the  hypo- 

*  Clin.  Soc.  Trans.,  1894. 


INJURIES  TO  THE  BILE  PASSAGES  55 

chondriac,  lumbar,  and  umbilical,  regions.  Fluctuation 
could  be  obtained,  and  the  tumour  gave  a  dull  note  on  percus- 
sion, but  was  neither  painful  nor  tender.  On  opening  the 
abdomen  above  the  umbilicus  in  the  middle  line,  the  tumour 
presented,  and  about  two  pints  of  thin,  clear,  yellowish  fluid 
were  removed  by  means  of  a  Spencer  Wells  cannula.  '  The 
cyst  was  found  to  have  extended  deeply  towards  the  trans- 
verse fissure  in  one  direction,  and  towards  the  umbilicus  to 
have  separated  widely  the  layers  of  the  suspensory  ligament 
of  the  liver.'  When  wiping  the  cavity,  some  ochry  fibrinous 
material  was  removed.  The  lower  part  of  the  abdominal 
wound  was  closed,  and  the  cyst  wall  brought  up  to  the  upper 
part  and  stitched  to  the  parietes,  drainage  being  effected  by 
a  tube  and  iodoform  gauze.  The  boy  made  an  excellent 
recovery,  and  left  the  hospital  within  six  weeks.  At  that 
time  the  liver  dulness  was  normal. 

Terrier  collected  twelve  cases  of  secondary  laparotomy  for 
injuries  to  the  bile-ducts  and  gall-bladder,  with  six  recoveries. 
If  rupture  of  the  common  duct  is  discovered  he  recom- 
mends ligature  of  both  ends  of  the  duct  and  chole- 
cystenterostomy. 


CHAPTER  IV 
INFLAMMATORY  AFFECTIONS 

Inflammatory  affections    may  be   conveniently  considered 
clinically  under  the  following  headings  : 

i.  Catarrhal  inflammation. 

(a)  Acute  catarrhal  cholangitis. 

(b)  Chronic  catarrhal  cholangitis. 

(c)  Chronic  catarrhal  cholecystitis. 

2.  Obliterative  cholecystitis  and  cholangitis. 

3.  Croupous   or   membranous   inflammation    of  the  gall- 
bladder and  bile-ducts. 

4.  Suppurative  inflammation. 

(a)  Simple  suppurative  cholecystitis,  or   suppurative 

catarrh,  or  simple  empyema  of  the  gall-bladder. 

(b)  Suppurative  and  infective  cholangitis. 

5.  Acute  parenchymatous  or  phlegmonous  cholecystitis  and 
gangrene  of  the  gall-bladder. 

6.  Ulceration  of  the  gall-bladder  and  bile-ducts. 

7.  Pericholecystitis  and  pericholangitis  with  adhesions. 

8.  Stricture  of  the  gall-bladder  and  bile-ducts. 

9.  Perforation  of  the  gall-bladder  and  bile-ducts. 
10.   Fistula  of  the  gall-bladder  and  bile-ducts. 

CATARRH  OF  THE  GALL-BLADDER  AND  BILE-DUCTS. 

The  larger  bile-ducts  and  the  gall-bladder,  being  lined 
with  mucous  membrane  having  cylindrical  epithelium  and 
glandular  diverticula,  are,  like  other  mucous  passages,  subject 
to  catarrh,  which  may  be  acute  or  chronic. 

[  56] 


INFLAMMATORY  AFFECTIONS  57 

As  acute  and  chronic  catarrhal  jaundice  are  subjects  of 
medical  rather  than  surgical  interest,  they  will  only  be  briefly 
considered  here ;  but  it  must  not  be  forgotten  that  chronic 
catarrhal  cholangitis,  by  simulating  jaundice  due  to  organic 
mischief,  or  from  its  frequent  association  with  serious 
disease,  such  as  cholelithiasis,  pancreatitis,  cancer,  or 
hydatids,  has  some  important  surgical  bearings,  and  that, 
when  medical  means  have  failed,  surgical  treatment  must  be 
considered. 

It  should  also  be  borne  in  mind  that  the  jaundice  accom- 
panying cancer  of  the  liver  is  frequently  catarrhal,  and 
therefore  capable  of  being  relieved  by  treatment,  although 
the  original  disease  persists.  Also,  that  the  evanescent 
jaundice  following  on  cholelithic  attacks  is  often  catarrhal, 
and  not  due  to  the  mechanical  obstruction  of  a  gall- 
stone. 

(a)  Acute  catarrh  gives  rise  to  the  evanescent  form  of 
icterus,  known  as  catarrhal  jaundice,  which,  more  frequently 
occurring  in  young  persons,  usually  comes  on  as  a  sequence 
of  dyspepsia  or  as  a  result  of  exposure  to  cold,  and  is 
ordinarily  unaccompanied  by  pain  or  serious  illness,  but  for 
which  help  is  sought  on  account  of  the  marked  objective 
symptom  of  jaundice. 

When  it  is  borne  in  mind  that  the  bile-ducts  have  only  a 
limited  calibre,  that  the  mucous  lining  is  capable  of  swelling 
so  as  to  occlude  the  passage,  and  that  the  secretion  of  bile 
takes  place  under  very  low  blood-tension  (according  to 
Naunyn,  no  to  220  minims  of  water),  and  is  therefore 
arrested  by  slight  backward  pressure,  it  is  easy  to  compre- 
hend how  catarrh  in  this  situation  should  lead  to  jaundice, 
though  absolute  proof  of  the  correctness  of  the  theory  is 
wanting,  since  simple  catarrhal  jaundice  furnishes  no  post- 
mortem subjects. 

Etiology. — An  extension  from  the  duodenum  is  probably 
the  usual  cause  of  acute  catarrhal  jaundice,  and  as  the 
common  bile-duct  traverses  the  walls  of  the  duodenum  very 
obliquely,  it  is  to  be  expected  that  the  narrow  terminal 
portion  of  the  duct  will  be  the  first  to  suffer,  and  be  the  seat 
of  the  primary  obstruction. 


58     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Beside  gastro-intestinal  catarrh,  exposure  to  cold,  exten- 
sion to  the  bile-ducts  of  inflammation  from  the  parenchyma 
of  the  liver,  carcinoma  of  the  liver,  gall-stones,  pancreatitis, 
hydatids,  pneumonia,  and  other  acute  inflammations  and 
infectious  fevers,  must  be  mentioned  as  causes  of  catarrh, 
direct  or  indirect.  Murchison  gives  gout  and  syphilis  as 
causes,  and  the  late  Dr.  Fagge  includes  under  this  heading 
jaundice  due  to  fright  and  that  occurring  in  epidemics. 
Although  it  is  well  known  that  in  cancer  of  the  liver  jaundice 
is  a  very  variable  sign,  it  is  not  always  recognised  that  the 
icterus  is  at  times  dependent  on  the  associated  catarrh, 
which  may  be  relieved  by  treatment,  though  the  original 
disease  persists.  It  is  well  known  that  the  typhoid  bacillus 
invades  the  gall-bladder  and  bile-ducts;  hence  the  jaundice 
that  occasionally  accompanies  enteric  fever  is  frequently  due 
to  catarrh,  and  has  usually  been  considered  a  rare  and  grave 
complication. 

Dr.  Ogilvie,  in  a  paper  in  the  British  Medical  Journal, 
January  12,  1901,  gives  a  number  of  cases  and  tables  from 
various  authorities  showing  the  frequency  of  jaundice  in 
typhoid  fever,  which  he  estimates  at  ij  per  cent.  The 
mortality  of  cases  of  jaundice  in  typhoid  fever  appears  to 
be  about  12^  per  cent.,  but  probably  some  of  these  cases  may 
be  pyaemic,  or  from  other  causes,  and  not  simply  catarrhal. 
There  is  a  form  of  epidemic  catarrhal  jaundice  known  as 
Weil's  disease,  which,  though  not  of  interest  surgically,  is  of 
great  importance  clinically. 

The  following  is  a  synopsis  from  a  description  of  the 
symptoms  by  Dr.  Herbert  Peck,  and  of  the  post-mortem 
appearances  by  Dr.  Arthur  Hall  {British  Medical  Journal, 
December  7,  1901). 

The  onset  is  gradual,  with  malaise,  loss  of  appetite,  and 
headache.  Sometimes  severe  abdominal  pain  and  cramps 
in  the  calves  of  the  legs  occur.  Usually  vomiting  comes  on 
after  two  or  three  days.  Diarrhoea  is  occasionally  present. 
Temperature  generally  between  ioo°  F.  and  1010  F. ;  severe 
rigors  sometimes  occur,  while  chilliness  and  shivering  are 
always  present.  Jaundice  usually  comes  on  a  day  or  two 
after   the   vomiting,  though  it  is  sometimes  delayed  for   a 


INFLAMMATORY  AFFECTIONS  59 

week,  while  occasionally  it  is  observed  earlier.  As  a  rule 
the  temperature  falls  to  normal  with  the  onset  of  jaundice, 
and  remains  so  afterwards.  The  liver  is,  as  a  rule,  tender, 
but  is  not  often  enlarged.  The  spleen  is  frequently  enlarged. 
Complications  observed  in  a  series  of  sixty-nine  cases  were : 
nephritis,  I  ;  acute  pneumonia,  2  ;  urticaria,  2  ;  and  1  fatal 
case. 

In  the  fatal  case  the  lobules  of  the  liver  consisted  of  a 
mass  of  loose,  shaggy,  irregular  connective  tissue,  large 
number  of  fat  cells  of  various  sizes,  liver  cells  in  all  stages 
of  fatty  degeneration,  some  retaining  their  size  and  form, 
but  full  of  minute  fat  globules,  others  granular  and  shrunken, 
and  the  rest  of  the  tissue  a  more  or  less  amorphous  debris. 
The  swollen  interlobular  bile-ducts  showed  distinct  evidences 
of  catarrh,  the  lining  epithelium  being  overgrown,  and  the 
lumina  in  places  completely  obstructed. 

The  kidneys  showed  marked  fatty  degeneration  of  the 
tubular  epithelium  of  the  cortex.  The  microscopical  appear- 
ances resemble  very  closely  those  seen  in  the  liver  and 
kidneys  in  acute  yellow  atrophy. 

As  the  symptoms,  diagnosis,  and  treatment  of  catarrhal 
jaundice  are  so  distinctly  subjects  of  medical  rather  than 
surgical  interest,  we  may  at  once  pass  on  to  consider  the 
chronic  form,  which  from  a  diagnostic  point  of  view  has 
important  surgical  bearings. 

(b)  Chronic  Cholangitis,  or  chronic  catarrh  of  the  bile-ducts, 
may  be  simply  a  sequel  to  the  acute  form,  and  may  then 
give  rise  to  a  more  or  less  persistent  jaundice,  leading  to  a 
suspicion  of  serious  organic  disease. 

Although  there  are  dyspeptic  symptoms  due  to  the  asso- 
ciated gastro-intestinal  catarrh,  with  jaundice  and  some  loss 
of  weight,  the  retention  of  strength  and  the  absence  of 
serious  sequelae,  such  as  ascites  and  haemorrhage,  generally 
enable  a  good  prognosis  to  be  given,  especially  as  the 
symptoms  usually  yield  to  proper  treatment. 

Catarrh  of  the  bile-ducts  probably  always  accompanies 
jaundice  from  whatever  cause,  and,  as  Dr.  Moxon  has 
pointed  out,  a  colourless  mucus  is  always  found  in  the  bile- 
ducts  when  an  obstruction  in  the  common  duct  is  complete. 


6o    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

A  search  through  the  pathological  records  of  Guy's  Hospital 
for  twenty  years  failed  to  discover  any  exception  to  this  rule. 
When  the  obstruction  is  only  partial,  the  mucus  may  be  well 
charged  with  bile,  as  the  backward  pressure  is  not  sufficient 
to  stop  the  secretion  and  pouring  out  of  bile  into  the  ducts. 

Specimen  1,420  in  Guy's  Museum  shows  dilated  bile-ducts 
in  the  liver  holding  a  pint  of  clear  mucus  (Fig.  21).  There 
was  a  small  cancerous  growth  in  the  common  duct.  Case  35 
is  a  good  example  of  a  similar  condition,  but  in  it  the 
obstruction  was  due  to  gall-stones. 

As  a  concomitant  of  cancer  of  the  liver  or  of  the  bile- 
ducts,  chronic  catarrh  is  common,  and  is  frequently  the 
cause  of  the  accompanying  icterus.  This  accounts  for  the 
relief  to  the  jaundice  afforded  by  treatment  in  a  necessarily 
fatal  disease ;  whereas,  when  the  jaundice  is  simply  de- 
pendent on  the  mechanical  pressure  of  the  growth  in  the 
ducts,  it  will  be  only  slightly,  or  not  at  all,  influenced  by 
remedies. 

The  same  remarks  apply  to  hydatid  disease,  to  abscess, 
and  to  other  organic  diseases  of  the  liver. 

Rolleston  and  Pigg  (Journal  of  Pathology,  vol.  v.)  relate  a 
most  interesting  case  of  chronic  cholangitis  and  perichol- 
angitis leading  to  a  suppurative  lymphangitis  in  the  portal 
spaces  of  the  liver.  Abscess  formation  gave  rise  to  throm- 
bosis and  destruction  of  the  portal  veins  resembling  pyle- 
phlebitis. They  believe  that  some  cases  of  pylephlebitis  due 
to  gall-stones  and  subsequent  catarrhal  cholangitis  are  in 
reality  examples  of  hepatic  lymphangitis  with  suppuration, 
eventually  invading  and  destroying  the  portal  vein. 

Cases  152,  157,  and  161  are  good  examples  of  chronic 
catarrhal  jaundice  produced  by  the  irritation  of  hydatid 
cysts  in  the  liver,  the  catarrh  and  its  accompaniment 
(jaundice)  being  cured  by  the  removal  of  the  cause. 

Gall-stones  are  probably  always  accompanied  by  catarrh, 
giving  rise  to  the  formation  of  thick  ropy  mucus,  which  leads 
to  attacks  of  pain  when  passing.  Some  of  the  minor  seizures 
of  pain  not  followed  by  jaundice — or  if  so,  only  to  a  slight 
extent — are  of  this  nature,  thus  accounting  for  the  relief  that 
frequently  follows  purely  medical  treatment  in  cholelithiasis, 


PLATE    IV. 


Fig.  21. — Chronic  Catarrh  with  Dilatation  of  Bile-ducts  in 
Liver.      Cancer  of  Common  Bile-duct. 

(No.  1,420,  Guy's  Museum.) 


To  face  p.  60.] 


INFLAMMATORY  AFFECTIONS  61 

giving  rise  to  the  erroneous  idea  that  the  cause  is  removed, 
whereas  the  gall-stones  generally  remain,  and  at  some  future 
date  may  cause  complications.  It  is  quite  a  common  event 
in  sudden  and  severe  gall-stone  seizures  occurring  in  middle 
life  or  in  advanced  age  to  have  a  history  of  '  spasms '  rive, 
ten,  or  even  twenty  years  before,  which  were  supposed  to 
have  been  cured  by  olive  oil  or  Carlsbad  waters,  or  some 
other  general  treatment,  so  that  in  all  sudden  seizures  in 
the  upper  abdominal  region  it  is  advisable  to  carefully  con- 
sider the  history  long  antecedent  to  the  attack  in  question. 

The  following  case  was  probably  one  of  chronic  cholan- 
gitis : 

Mrs.  H.,  aged  forty-six,  admitted  into  the  Leeds  General 
Infirmary,  August  28,  1900,  with  a  history  of  typical  attacks 
of  gall-stone  colic  for  two  years,  with  slight  transient  jaun- 
dice. No  enlargement  of  the  gall-bladder  could  be  felt, 
but  tenderness  on  pressure  was  present.  No  jaundice  at  the 
time  of  examination.  The  patient  was  given  oleate  of  soda 
pills  and  Carlsbad  salts,  and  careful  dieting  was  ordered. 

A  letter,  dated  January  27,  1903,  says  that  she  has  been 
quite  free  from  her  former  attacks,  and  that  her  general 
health  is  much  improved. 

Although  the  jaundice  in  cholelithiasis  is  usually  produced 
by  a  gall-stone  obstructing  the  common  or  hepatic  duct,  it 
is  undoubtedly  true  that  in  many  cases  jaundice  is  present 
wrhen  the  concretion  is  in  the  gall-bladder  or  in  the  cystic 
duct,  the  obstruction  to  the  flow  of  bile  being  caused  by  an 
inflammatory  swelling  of  the  mucous  membrane  of  the  bile 
channels  caused  by  extension  from  the  seat  of  obstruction ; 
in  other  words,  the  jaundice  is  dependent  on  catarrhal 
inflammation.  This  occurs  also  in  many  cases  where,  after 
cholecystotomy  has  been  performed  and  gall-stones  have 
been  removed  from  the  gall-bladder  and  cystic  duct,  and  the 
common  duct  has  been  shown  to  be  free  of  all  concretions, 
all  the  bile  flows  for  several  days  through  the  tube  introduced 
into  the  gall-bladder — that  is,  until  the  inflammatory  swelling 
of  the  mucous  membrane  of  the  common  duct  has  had  time 
to  subside. 

Riedel    (Gumprecht,    Deutsch.   Med.    Woch.,   1S95,   No.    15) 


62     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

states  that  about  two-fifths  of  the  cases  of  jaundice  in 
cholelithiasis  arise  in  this  way.  He  quotes  one  case  where 
the  gall-stone  was  outside  the  bile  channel  in  a  perforative 
abscess  cavity,  and  in  a  case  {British  Medical  Journal,  May  25, 
1895)  seen  with  Dr.  Chadwick  at  the  Leeds  Infirmary  this 
was  so. 

The  treatment  of  chronic  catarrhal  jaundice  is  at  first 
medical,  and  if  the  disease  prove  obstinate  a  course  of  treat- 
ment at  Leamington,  Bath,  Harrogate,  or  Carlsbad,  will  be 
likely  to  do  good  if  the  ailment  be  functional  ;  but,  that 
failing,  the  question  of  some  organic  cause  that  may  be 
removable  by  surgical  treatment  should  be  considered. 

Dr.  Thudichum,  who  published  a  treatise  on  gall-stones 
in  1863,  describes  a  catarrh  of  the  finest  ramifications  of 
the  bile-ducts  which  causes  their  lining  to  be  shed  in  the 
shape  of  biliary  casts.  He  considers  that  these  often  form 
the  nucleus  of  gall-stones  where  the  catarrh  is  associated 
with  decomposition  of  bile  due  to  bacteria  invading  the 
obstructed  bile-ducts. 

This  has  been  termed  by  Meckel  'lithiatic  catarrh';  perhaps 
a  better  term  is  desquamating  angiocholitis,  or  stone-forming 
catarrh  of  the  bile-ducts. 

It  doubtless  has  great  etiological  importance  in  reference 
to  gall-stones,  especially  when  associated  with  decomposition 
due  to  the  presence  of  micro-organisms  in  the  stagnant  fluid 
in  the  ducts. 

(c)  Catarrhal  cholecystitis,  or  chronic  catarrh  of  the  gall- 
bladder without  jaundice,  forms  a  distinct  and  definite 
disease,  and  we  have  seen  several  cases  in  which  chole- 
lithiasis had  been  diagnosed  and  operation  advised,  but  where 
neither  the  gall-bladder  nor  ducts  contained  anything  firmer 
than  thick  ropy  mucus,  which  was  apparently  the  cause  of 
painful  contractions  of  the  gall-bladder  simulating  gall-stone 
seizures. 

In  one  case  of  this  kind,  in  a  lady  of  sixty,  the  gall-bladder 
contained  bile  mixed  with  thick  mucus,  which  formed  plugs 
almost  like  small  grains  of  boiled  sago ;  there  were  no  other 
signs  of  disease,  but  the  gall-bladder  was  very  large  and 
pouched,    and    the    mucous   membrane   thickened.      Chole- 


INFLAMMATORY  AFFECTIONS  63 

cystotomy  was  performed,  and  the  drainage  was  continued 
for  a  fortnight,  after  which  the  wound  was  allowed  to  close. 
The  patient  continues  well,  and  is  freed  from  her  previously 
frequently  recurring  attacks.     (Case  101.) 

Specimen  No.  1,416  in  Guy's  Museum  may  be  a  case  of 
this  kind  ;  it  shows  a  gall-bladder  distended  with  mucus, 
although  there  was  no  organic  obstruction  in  the  ducts.  It 
was  removed  from  a  patient  of  Mr.  Cock's  who  died  from 
pyaemia  following  on  acute  necrosis. 

In  yet  another  case,  in  a  lady  of  thirty-two,  the  history  of 
gall-stones  was  most  characteristic,  and,  from  the  adhesions 
found  at  the  time  of  operation,  there  can  be  no  doubt  that  at 
some  time  they  had  been  present.  At  the  time  of  operation, 
the  gall-bladder  and  ducts  were  free  from  concretions,  though, 
on  opening  the  gall-bladder,  thick  mucus  like  that  mentioned 
as  having  been  present  in  Case  101  was  found. 

Cholecystotomy  and  drainage  for  a  week  brought  about 
relief,  and,  although  there  was  some  repetition  of  the  attacks, 
doubtless  from  the  drainage  not  having  been  continued 
sufficiently  long,  persistence  with  appropriate  medical  treat- 
ment effected  a  cure,  and  the  patient  is  now  quite  well. 
(Case  97.) 

Case  165  is  one  of  the  most  marked  examples,  and,  as  it 
occurred  in  a  lady  medically  trained,  who  made  her  own 
diagnosis  in  the  first  instance,  it  has  especial  value,  since  it 
shows  that  the  attacks  due  to  catarrhal  cholecystitis  were 
equally  severe  with  those  undoubtedly  due  to  gall-stones. 
In  the  early  attacks  gall-stones  were  passed  and  discovered 
in  the  motions ;  the  attacks  persisting,  operation  was  done, 
and  catarrhal  cholecystitis  only  was  discovered.  Drainage 
of  the  gall-bladder  effected  a  cure,  and  the  patient  remained 
quite  well  some  years  later. 

In  another  instance,  in  a  lady  of  fifty-five,  seen  in  con- 
sultation with  Dr.  Parke  of  Milnsbridge,  two  months  after  a 
negative  abdominal  exploration  had  been  made,  the  charac- 
teristic gall-stone  attacks  were  persisting;  and  after  each 
temporary  jaundice  was  noticed.  In  this  case  the  gall- 
bladder had  not  been  drained ;  hence  no  good  resulted  from 
the  operation. 


64     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Dr.  Byron  Robinson  describes  a  case*  in  which  there 
were  attacks  of  pain  like  cholelithic  seizures,  and  which,  he 
thought,  were  dependent  on  kinking  of  the  common  bile- 
duct,  producing  obstruction  to  the  flow  of  bile  into  the 
duodenum,  but  which  may  probably  be  more  readily  explained 
on  the  hypothesis  that  it  was  a  case  of  chronic  catarrhal 
cholecystitis.  It  came  on  six  months  after  the  removal  of 
gall-stones  from  the  gall-bladder.  On  opening  the  abdomen, 
the  gall-bladder,  though  free  from  stones,  was  found  to  be 
considerably  enlarged,  although  the  duct  was  patent,  as 
proved  by  syringing  water  through  it  into  the  duodenum. 
Cholecystotomy  resulted  in  recovery. 

In  these  cases  the  gall-bladder  is  usually  distended,  but  it 
rarely  forms  a  distinct  tumour,  and  there  is  an  absence  of 
pain  on  pressure  over  it.  Unless  gall-stones  have  been 
present  at  some  time,  there  are  usually  no  adhesions  of  the 
gall-bladder  or  ducts  to  the  neighbouring  viscera,  proving 
that  the  inflammation  has  not  extended  through  to  the 
peritoneal  coat,  as  it  usually  does  when  dependent  on  chole- 
lithiasis. 

This  catarrh  may  be  the  sequence  of  gall-stone  irritation, 
as  in  Cases  97  and  165,  but  in  other  instances  may  probably 
be  due  to  the  dependent  position  of  the  fundus  of  the  gall- 
bladder, or  to  chronic  constipation  and  accumulation  of 
faeces  in  the  hepatic  flexure  of  the  colon  interfering  with  the 
regular  emptying  of  the  gall-bladder. 

In  all  probability,  in  not  a  few  of  the  cases  where  adhesions 
are  found  around  a  contracted  gall-bladder,  and  no  concre- 
tions are  met  with,  the  attacks  are  kept  up  by  catarrh  of  the 
gall-bladder  and  ducts,  which  it  is  next  to  impossible  to 
diagnose  from  the  ordinary  gall-stone  seizures.  Case  111 
is  a  good  example.  The  benefit  derived  from  a  systematic 
course  of  treatment  in  these  cases  renders  it  advisable  that 
medical  should  always  precede  surgical  treatment. 

The  diagnosis  from  cholelithiasis  may  usually  be  made  by 

observing  that  the  attacks  are  less  severe  and  less  prolonged 

than  in  true  gall-stone  seizures  ;  that  no  gall-stones  are  found 

in   the  evacuations  after   an   attack ;    that  jaundice  seldom 

*  American  Medico-Surgical  Bulletin,  April  18,  1896. 


INFLAMMATORY  AFFECTIONS  65 

supervenes,  and  if  it  does  is  only  very  slight ;  that  there  is  no 
tenderness  on  pressure  between  the  ninth  costal  cartilage  and 
the  umbilicus  ;  and  that  the  affection  will  usually  completely 
yield  to  treatment.  Should  medical  treatment  fail  to  relieve, 
it  may  be  difficult  to  distinguish  chronic  catarrh  of  the  gall- 
bladder from  cholelithiasis  ;  but  if,  under  the  belief  that  the 
case  is  one  of  gall-stones,  the  gall-bladder  be  exposed,  and  no 
concretions  found,  cholecystotomy,  followed  by  drainage,  will 
be  likely  to  effect  a  cure. 

In  chronic  catarrh  of  the  gall-bladder,  regular  exercise, 
massage  over  the  hepatic  region,  the  avoidance  of  anything 
tight  around  the  waist  which  will  increase  the  dependence  of 
the  fundus  of  the  gall-bladder,  careful  regulation  of  the  diet, 
and  the  judicious  employment  of  saline  aperients,  should  be 
in  all  cases  adopted. 

The  spasmodic  attacks  may  require  the  administration  of 
a  sedative,  and  I  have  found  10  grains  of  aspirin  of  great 
service.  The  dose  may  be  safely  repeated  in  an  hour  or  two 
if  required ;  but  in  some  cases,  like  those  referred  to,  nothing 
short  of  a  subcutaneous  injection  of  morphia  will  do  any 
good. 

If,  after  a  few  weeks  of  general  treatment,  the  symptoms 
are  not  relieved,  the  case  will  probably  be  thought  to  be  one 
of  gall-stones,  and  operative  treatment  may  be  considered 
advisable. 

Even  if  the  gall-bladder  and  ducts  be  found  free  from  gall- 
stones, cholecystotomy  and  drainage  should,  nevertheless,  be 
performed  ;  and  it  will  be  found  useful  after  the  third  day  to 
gently  syringe  a  little  warm  water,  previously  rendered  sterile 
by  boiling,  through  the  drainage-tube  daily,  so  as  to  wash  out 
the  ducts ;  and  after  a  fortnight  or  more  the  tube  may  be 
left  out,  and  the  wound  allowed  to  close. 

General  treatment  directed  to  the  cause  should  be  con- 
tinued for  some  time  afterwards.  In  fact,  obstinate  catarrh 
of  the  gall-bladder  should  be  treated  like  catarrh  of  the 
urinary  bladder,  first  by  medical  and  general  remedies  ;  and 
these  failing,  physiological  rest  should  be  secured  by  means 
of  drainage. 


66     DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

OBLITERATIVE  CHOLECYSTITIS  AND  CHOLANGITIS. 

It  is  now  well  recognised  that  repeated  attacks  of  appendi- 
citis may  ultimately  lead  to  obliteration  of  the  vermiform 
appendix,  which  may  be  discovered  as  a  simple  cord  without 
any  lumen  in  the  centre  of  firm  adhesions.  I  have  seen  the 
condition  on  several  occasions. 

The  same  state  may  be  brought  about  in  the  gall-bladder 
and  bile-ducts  by  repeated  attacks  of  inflammation,  so  that  it 
is  not  very  uncommon  to  find  the  gall-bladder  and  cystic 
duct  represented  by  a  mere  fibrous  cord,  surrounded  by 
adherent  viscera,  and  unless  carefully  sought  for,  it  may 
be  thought  that  they  have  been  congenitally  absent,  as  in 
Case  209. 

Between  this  form,  which  may  be  conveniently  termed 
obliterative  cholecystitis,  and  the  ordinary  contracted  gall- 
bladder so  frequently  seen  in  operating  for  gall-stones,  every 
degree  of  deformity  may  exist. 

The  gall-bladder  may  be  only  partly  obliterated,  and  the 
small  amount  of  mucous  membrane  left  may  continue  to 
secrete  a  little  mucus,  and  keep  up  a  constant  state  of 
irritation  resembling  true  gall-stone  seizures,  as  in  Case  259; 
or  the  cystic  duct  may  be  obliterated,  and  the  gall-bladder 
may  form  a  cyst  containing  mucus  quite  separated  from 
the  bile  channels  proper,  as  in  Case  2.  In  nearly  all  these 
cases  the  recurring  pains  call  for  operation,  and  unless  the 
apparently  insignificant  and  almost  obliterated  remains  be 
taken  away,  the  attacks  of  pain,  often  associated  with  fever, 
will  continue,  and  lead  to  serious  deterioration  of  health. 
This  was  shown  in  the  following  case  : 

Case  229. — Cholecystotomy — Recurrence  of  Symptoms  — 
Cholecystectomy — Recovery. — Mr.  S.,  aged  fifty-six,  seen  with 
Dr.  Cattle  and  Dr.  Anderson,  of  Nottingham,  for  loss  of 
flesh,  general  ill-health,  and  frequently  recurring  pains  in 
the  right  hypochondrium,  the  illness  being  of  several  years' 
standing. 

Cholecystotomy,  September  4, 1898. — Contracted  gall-bladder, 
with  adhesions  to  surrounding  parts,  the  result  of  gall-stone 
irritation.     Cholecystotomy  performed,  the  gall-bladder  being 


INFLAMMATORY  AFFECTIONS  67 

isolated  by  a  gauze  drain.  This  was  followed  by  relief  for 
some  months,  when  the  painful  attacks  recurred,  accompanied 
by  rigors  and  slight  catarrhal  jaundice. 

Cholecystectomy. — A  further  operation  was  advised,  and  on 
September  3,  1899,  the  shrivelled  gall-bladder,  containing 
muco-pus,  was  removed,  a  small  tube  being  passed  into  and 
fixed  in  the  cystic  duct.  Bile  flowed  freely  the  next  day. 
Ultimately  the  patient  made  a  complete  recovery,  and  when 
seen  in  1902  he  was  in  robust  health,  and  said  he  had  had  no 
further  trouble. 

This  and  other  similar  cases  of  contracted  gall-bladder  led 
me  to  adopt  the  operation  of  cholecystectomy  in  certain 
cases,  where  to  leave  the  gall-bladder  means  leaving  a  useless 
and  diseased  appendage  lined  with  mucous  membrane  that  is 
certain  to  secrete  mucus,  which  is  apt  to  be  retained,  owing 
to  the  cystic  duct  contracting  and  becoming  strictured  as  the 
result  of  long-continued  irritation  and  ulceration.  This 
mucus,  retained  under  tension,  becomes  infected,  and  a 
state  of  affairs  much  resembling  chronic  appendicitis  is  apt 
to  continue,  until  either  the  gall-bladder  undergoes  atrophy 
and  absorption,  or  the  patient  is  worn-out  by  repeated  pain 
and  chronic  septicaemia,  unless  a  further  operation  is  under- 
taken to  remove  the  offending  organ. 

Case  22. — Removal  of  Gall-stone — Persistent  Fistula — Chole- 
cystectomy— Recovery.— Mrs.  S.  G.,  aged  forty-nine,  operated 
on  in  1888  for  gall-stones  (when  sixty-six  small  ones  were 
removed  from  a  contracted  and  ulcerated  gall-bladder  and 
cystic  duct),  was  left  with  a  mucous  fistula,  which  had  to  be 
kept  open  by  a  tube,  as,  if  it  was  allowed  to  heal,  pain  and 
fever  resulted.  On  May  14,  1890,  a  further  operation  was 
performed,  when  the  gall-bladder  was  found  shrivelled  and 
adherent  and  the  cystic  duct  was  strictured.  The  operation 
of  cholecystectomy  was  performed,  and  a  complete  recoverv 
resulted,  the  patient  being  well  when  heard  of  several  vears 
later. 

Case  in.  —  Cholecystectomy  —  Recovery. —  Mr.  M.,  a^ed 
forty-six,  seen  with  Dr.  R.,  of  New  York,  and  Dr.  MacGeagh, 
of  London,  for  frequent  seizures  of  intense  pain,  resembling 
biliary  colic,  with  irregular  fever  and  great  loss  of  flesh  and 

5—2 


68     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

strength.  At  the  operation  on  May  2,  1895,  I  found  an 
inflamed  and  contracted  gall-bladder,  with  cholangitis  and 
extensive  adhesions,  doubtless  due  to  gall-stones  that  had 
passed.  After  opening  the  gall-bladder  and  clearing  away 
muco-pus,  the  organ  was  excised  and  the  duct  was  plugged 
with  gauze,  brought  to  the  surface  through  a  tube.  Recovery 
was  uninterrupted,  and  he  was  able  to  sail  at  the  month-end. 
Eight  years  later  he  was  in  perfect  health. 

So-called  congenital  obliteration  of  the  bile-dncts,  which  was 
briefly  referred  to  on  p.  12,  and  is  illustrated  by  a  photograph  of 
a  specimen  (Fig.  22),  has  engaged  the  attention  of  several 
pathologists.  Dr.  John  Thomson  ('  Congenital  Obliteration 
of  the  Bile-ducts,'  Edinburgh,  1892)  collected  fifty  cases  ; 
Dr.  Rolleston  has  referred  to  nine  others  (British  Medical 
Journal,  March  30,  1901)  ;  and  Dr.  G.  Parker  (Lancet, 
August  24,  1901)  to  three  additional  ones. 

The  following  account  of  Dr.  Rolleston's  case  and  his 
remarks  on  the  pathogeny  are  so  complete  that  I  make  no 
apology  for  quoting  it  at  length  : 

History. — A  male  child,  aged  six  months,  had  been  jaun- 
diced since  birth.  It  was  treated  as  an  out-patient  with 
mercury  and  chalk,  magnesium  sulphate,  and  podophyllin. 
The  jaundice  varied  from  time  to  time,  and  the  child's 
nutrition  was  fairly  preserved.  A  fortnight  before  death  the 
jaundice  became  more  marked,  and  on  May  28,  1897,  the 
child  was  admitted  under  Dr.  Ridge  Jones,  to  whom  we  are 
indebted  for  permission  to  publish  the  case. 

Condition  on  Admission. — The  child  had  universal,  but  not 
extreme,  jaundice.  There  was  some  erythema  in  the  left 
axilla.  The  liver  was  much  enlarged,  and  came  down  to  the 
anterior  superior  spine  of  the  ilium.  The  spleen  was  also 
enlarged,  and  projected  three  fingers'  breadth  below  the 
costal  arch.  There  was  no  ascites.  The  urine  was  bile- 
stained  and  the  motions  clay-coloured. 

On  June  5  the  temperature  went  up  to  1020  F.,  and  the 
child  died,  after  bringing  up  blood  from  the  lungs. 

The  child  was  the  first-born,  and  presented  no  signs  of  con- 
genital syphilis. 

Necropsy. — The  necropsy   was  performed   by  Dr.    Hayne. 


PLATE  V. 


Fig.  22. — Congenital  Obliteration  of  Bile-ducts. 
(No.  973,  St.  Mary's  Museum.) 


To  face  p.  68.] 


INFLAMMATORY  AFFECTIONS  69 

The  body  was  thin,  and  all  the  organs  and  tissues  were  bile- 
stained.  The  oesophagus  was  normal,  and  free  from  staining 
by  blood.  The  pleurae  were  healthy.  The  trachea  contained 
blood.  Blood  was  found  to  have  been  aspirated  into  both 
lungs,  which  showed  emphysematous  bullae  and  some  small 
caseous  masses  ;  the  latter  were  chiefly  close  to  the  surface 
of  the  lung.  Microscopically,  these  caseous  areas  showed 
broncho-pneumonia,  with  early  caseation,  but  no  definite 
evidence  of  tuberculosis.  One  of  the  tracheal  glands  was 
enlarged  and  caseous. 

Condition  of  Liver. — The  liver  weighed  12  ounces,  or  nearly 
twice  the  normal  weight.  Holt  gives  7*5  ounces  as  the 
normal  weight  of  the  liver  for  a  child  of  six  months,  while, 
according  to  Birch-Hirschfeld,  6  ounces  is  the  average 
weight.  It  was  much  enlarged,  yellow  in  colour,  and  mani- 
festly cirrhotic.  The  common  bile-duct  was  small,  and  as 
its  lower  half  was  transformed  into  a  slender  fibrous  cord, 
considerable  difficulty  was  experienced  in  finding  it  and  in 
distinguishing  it  from  the  hepatic  artery.  The  gall-bladder 
was  small,  thickened,  collapsed,  and  buried  in  adhesions ; 
the  cystic  duct  was  represented  by  a  thin  fibrous  cord. 
There  were  enlarged  glands  in  the  portal  fissure,  suggesting 
the  condition  found  in  hypertrophic  biliary  cirrhosis.  The 
liver  cut  like  a  cirrhotic  liver,  and  showed  fibrosis. 

Microscopic  Examination. — Microscopic  sections  were  taken 
from  various  parts  of  the  liver ;  fibrosis  was  everywhere 
present,  but  the  appearances  varied  in  different  situations. 
Where  the  fibrosis  was  least  marked  there  was  monolobular 
cirrhosis,  the  fibrous  tissue  being  old,  and  including  a  large 
number  of  newly-formed  bile-ducts.  In  other  situations, 
where  the  cirrhosis  was  multilobular,  there  were  areas  of 
extensive  fibrosis,  including  compressed  liver  cells  and  small 
bile-ducts.  Some  of  the  latter  were  dilated,  and  contained 
plugs  of  inspissated  bile.  The  cirrhosis  was  everywhere  old 
and  not  progressive.  The  liver  cells  inside  the  lobules  were 
in  a  very  fair  state  of  nutrition ;  the  trabecular  arrangement 
was  disturbed,  and  the  columns  of  liver  cells  were  separated 
from  each  other  by  spaces,  which,  however,  appeared  empty. 

The  appearances  are,  therefore,  those  of  a  mixed   mono- 


70     DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

lobular  and  multilobular  cirrhosis.  Sections  of  the  common 
bile-duct  near  its  obliteration  show  very  considerable  fibrotic 
thickening  of  its  walls,  with  complete  alteration  of  its  normal 
appearance  and  absence  of  its  mucous  glands.  In  the  lumen 
there  is  debris,  consisting  of  inspissated  bile  pigment  and  the 
necrosed  remains  of  inflammatory  tissue.  No  trace  of  any 
normal  epithelial  lining  can  be  made  out.  The  fibrous  wall 
is  infiltrated   for  some  distance   by  globules  of  inspissated 


Fig.  23. — Transverse  Section  of  Common   Bile-Duct  Close  to  its 
Obliteration,  Under  a  Low  Power  (x  35). 

Shows  altered  and  fibrosed  walls  of  duct,  and  absence  of  mucous  glands  and 
of  the  lining  epithelium.  The  small  black  spots  infiltrating  the  walls  of 
the  duct  are  microscopic  masses  of  inspissated  bile,  not  nuclei. 

bile.  In  the  accompanying  section,  drawn  under  a  low 
power,  the  debris  might  at  first  sight  suggest  desquamated 
epithelium,  but  examination  under  a  high  power  does  not 
support  this.  The  debris  shows  necrotic  fibrous  tissue,  a  few 
spindle-shaped  nuclei,  and  small  masses  of  inspissated  bile. 

The  spleen  weighed  2!  ounces,  and  was  extremely  diffluent. 
The  heart,  pericardium,  kidneys,  and  other  organs,  except  for 
bile  staining,  were  normal. 

Remarks  by  Dr.  Rolleston. — This  case  is  recorded  not  only 


INFLAMMATORY  AFFECTIONS  71 

on  account  of  its   comparative  rarity,  but  also  in  order  to 
discuss  briefly  the  nature  of  the  morbid  process. 

Treves's  case  was  successfully  operated  upon  at  the  age  of 
nineteen  years  for  jaundice   of  sixteen  years'  duration,  and 
obliteration  and  absence  of  the  lower  end  of  the  bile-duct 
was  found.     It  differs  so  markedly  from  all  other  cases  that 
it    might    be    questioned    whether   it    belongs    to    the    same 
category.     Jaundice  did  not  begin  till  the  age  of  two  years, 
instead  of  a  day  or  two  afterbirth.     Possibly,  though  Treves 
does  not  suggest  it,  the  obliteration  of  the  duct  was  due  to 
the  effects  of  a  calculus  lodging  in  the  duct  at  or  about  the 
time  of  the  onset  of   the  jaundice.      Thomson  (Edinburgh 
Hospital   Reports,    vol.   v.,   1898)    considers    that    the   same 
morbid  process  is  at  work   in  cholelithiasis  in  infants  as  in 
congenital  obliteration  of  the  bile-ducts,  and  supports  this 
suggestion  by  quoting  two  cases  of  infantile  cholelithiasis  in 
which  the  biliary  apparatus  was  abnormal  (Cuffer,  Bouisson). 
Treves's  remarkable  case   may  perhaps,   therefore,  be    con- 
sidered as  allied  to,  if  not  a  very  slightly  marked  example  of, 
the  same  class.  It  may  be  mentioned  that  two  other  cases  have 
been  operated  upon,  though  unsuccessfully  (Giese,  Putnam). 
Sex. — In  Thomson's  casesthesex  was  given  in  thirty-four,  and 
showed  a  preponderance  of  males — twenty-one  males,  thirteen 
females.     In  the  nine  other  cases,  six  were  females  and  three 
males,  making  in  all  twenty-four  males  to  nineteen  females. 

Pathogeny. — Dr.  John  Thomson,  in  his  monograph  on  the 
subject,  believed  that  in  the  great  majority  of  cases  there 
was,  to  start  with,  a  congenital  malformation  of  the  ducts 
which  narrowed  the  available  lumen.  This  obstruction  to 
the  free  exit  of  bile  disposed  to  catarrh,  blocking,  and, 
finally,  to  obliteration  of  the  ducts.  As  a  result  of  the 
obstruction  to  the  free  passage  of  bile  into  the  duodenum, 
biliary  cirrhosis  was  started.  In  a  later  article  contributed 
to  Allbutt's  '  System  of  Medicine '  (vol.  iv.,  p.  253)  this  writer 
so  far  modifies  his  views  as  to  omit  any  reference  to  a 
primary  congenital  abnormality  as  a  factor  in  the  condition. 
The  process  is  regarded  as  a  descending  cholangitis  set  up 
by  irritative  bodies  in  the  bile,  compared  to  toluylendiamine. 
When  the  disease  has  gone  so  far  as  to  interfere  with  the 


72     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

free  passage  of  bile  from  the  liver,  biliary  cirrhosis  develops, 
as  in  Charcot  and  Gombault's  experimental  ligature  of  the 
bile-ducts  in  guinea-pigs. 

Ford,  in  a  recent  paper  on  obstructive  biliary  cirrhosis,  has 
collected  twenty-four  cases  since  1882  where  cirrhosis  of  the 
liver  was  associated  with,  and,  as  he  believes,  due  to,  obstruc- 
tion of  the  common  duct.  Of  these  twenty-four  cases,  no 
fewer  than  nine  are  examples  of  congenital  obliteration  of 
the  bile-ducts.  In  fact,  his  statistical  proof  that  biliary 
obstruction  per  se  induces  cirrhosis  of  the  liver  rests  in  some 
measure  on  cases  of  congenital  obliteration  of  the  ducts. 

It  is  a  point  of  significant  interest  that  cirrhosis  of  the 
liver  is  comparatively  rarely  found  in  association  with  obstruc- 
tion of  the  bile-ducts  in  adults,  and  when  present  is  usually 
associated  with  gall-stones  and  infection  of  the  ducts,  while 
cirrhosis  seems  to  be  a  definite  accompaniment  of  congenital 
obliteration  of  the  ducts.  In  Thomson's  fifty  cases  a 
microscopic  examination  was  only  made  in  ten,  and  in  all 
but  one  of  these  it  is  stated  that  cirrhosis  was  present ;  in 
eight  other  cases  that  I  have  notes  of  cirrhosis  was  present 
in  at  least  seven.  The  omitted  case  is  that  described  by 
Dr.  Ross,  to  which  further  reference  is  made  below. 

The  question  therefore  arises  whether  there  is  any  evidence 
to  support  the  theory  that  cirrhosis  in  these  cases  is  depen- 
dent on  the  obliteration  of  the  larger  bile-ducts.  If  it  can 
be  established  that  the  change  in  the  bile-duct  is  older  and 
more  advanced  than  that  in  the  liver,  there  is  fair  ground  for 
regarding  the  hepatic  lesion  as  due  to  the  obstruction  in  the 
ducts.  In  a  recently  recorded  case  Ross  describes  oblitera- 
tion of  the  common  bile-duct  near  the  duodenum  in  a  female 
child,  aged  three  months,  whose  liver  showed  small-celled 
infiltration  around  the  bile-ducts  rather  than  fibrosis.  In 
this  instance  it  must  be  admitted  that  the  evidence  points  to 
the  change  in  the  bile-duct  being  the  older.  On  the  other 
hand,  in  our  case,  and  as  far  as  one  can  judge  in  the  others, 
the  fibrosis  in  the  liver  is  quite  as  old  as  the  lesion  in  the 
bile-ducts.  Thomson  ('  Congenital  Obliteration  of  the  Bile- 
ducts,'  Edinburgh,  1892),  refers  to  seven  cases  of  infantile 
jaundice    with    symptoms    similar   to   those     of    congenital 


INFLAMMATORY  AFFECTIONS  73 

obliteration  of  the  bile-ducts,  but  with  pervious  ducts ;  they 
proved  fatal  at  seventeen  days  of  age  on  an  average,  instead 
of  at  two  and  a  half  months,  as  in  congenital  obliteration  of 
the  ducts.  '  This  suggests  that  they  are  merely  earlier  cases 
of  the  same  condition — before  the  blocking  has  occurred.' 

The  following  hypothesis  appears  to  be  a  reasonable 
explanation  of  the  pathogeny  of  so-called  congenital  oblitera- 
tion of  the  bile-ducts  :  In  the  first  instance,  poisons  pass  by 
the  blood  from  the  placenta  to  the  foetus  by  the  umbilical 
vein  ;  some  of  this  blood  at  once  passes  through  the  liver, 
and,  in  virtue  of  the  toxic  effect  of  the  contained  body  or 
bodies,  induces  ordinary  portal  or  multilobular  cirrhosis  of 
the  liver.  The  rest  of  the  blood  in  the  umbilical  vein  passes 
directly  into  the  general  circulation  of  the  foetus  by  the 
ductus  venosus,  and  subsequently,  by  means  of  the  hepatic 
artery,  will  convey  poison  to  the  liver.  By  this  means  the 
toxic  body,  which,  as  Thomson  suggests,  may  be  analogous 
to  toluylendiamine,  is  excreted  into  the  small  intrahepatic 
bile-ducts,  setting  up  cholangitis  and  monolobular  cirrhosis, 
like  that  seen  in  hypertrophic  biliary  cirrhosis.  In  this  way 
a  mixed  cirrhosis  (portal  and  biliary)  is  induced.  The 
cholangitis  descends  to  the  larger  ducts,  and  gives  rise  to  an 
obliterative  cholangitis — a  process  analogous  to  obliterative 
appendicitis.  The  difference  between  this  condition  of  con- 
genital (umbilical)  cirrhosis  with  obliterative  cholangitis  and 
other  forms  of  cirrhosis  in  post-natal  life  consists  in  the 
further  change  in  the  large  bile-ducts  and  gall-bladder.  An 
attempt  to  explain  this  additional  lesion  may  be  made  as 
follows  :  The  bile-ducts  are  extremely  small  at  birth,  and  any 
inflammatory  change  will,  from  the  small  size  of  the  lumen, 
produce  stenosis  much  more  readily  than  later  in  life.  An 
analogous  effect  is  seen  in  the  fact  that  laryngeal  obstruction 
in  diphtheria  is  more  frequent  in  young  subjects  than  in  older 
patients,  quite  apart  from  the  much  greater  frequency  of  the 
disease  in  the  young.  The  opposed  inflamed  surfaces  of  the 
bile-ducts  will  also  come  in  contact  more  readily,  and,  as  in 
catarrhal  appendicitis,  obliteration  might  result.  The  follow- 
ing considerations  bear  on  the  hypothesis  that  the  disease  is 
primarily  a  congenital  cirrhosis  : 


74     DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

i.  The  almost  constant  occurrence  of  cirrhosis  in  these 
cases  of  bile-duct  obstruction  in  infants  as  compared  with 
the  frequency  and  irregularity  with  which  cirrhosis  follows 
obstruction  of  the  larger  bile-ducts  in  later  life.  The  mixed 
character  of  the  cirrhosis  explains  the  discrepancy  in  the 
recorded  cases,  some  authors  speaking  of  biliary,  others  of 
multilobular,  cirrhosis. 

2.  The  large  size  of  the  liver  :  this  resembles  hypertrophic 
biliary  cirrhosis.  In  simple  obstruction  of  the  larger  bile- 
ducts  in  adults,  the  liver,  though  swollen  from  retained  bile 
in  the  early  stages,  is  usually  small  after  death. 

3.  The  large  size  of  the  spleen — a  phenomenon  not  met 
with  in  uncomplicated  biliary  obstruction.  The  large  size  of 
the  spleen  is  best  explained  as  the  result  of  toxic  bodies 
reaching  the  organ  by  the  splenic  artery.  In  hereditary 
syphilis,  where  it  is  probable  that  the  poison  reaches  the 
liver  by  the  umbilical  vein,  and  is  derived  from  the  maternal 
circulation  rather  than  that  the  ovum  is  infected  by  a 
syphilitic  spermatozoon,  there  is  a  similar  splenic  enlarge- 
ment. In  both  conditions  there  is  cirrhosis  due  to  poisons 
arriving  by  the  umbilical  vein  ;  the  difference  between  the 
pericellular  cirrhosis  of  hereditary  syphilis  and  the  mixed 
(monolobular  and  multilobular)  cirrhosis  of  so-called  con- 
genital obliteration  of  the  bile-ducts  must  depend  on  a 
difference  in  the  poisons  in  the  two  diseases.  This  is  at  one 
with  Thomson's  statistical  proof  that  syphilis  plays  no  part 
in  the  antecedents  of  so-called  congenital  obliteration  of  the 
bile-ducts. 

4.  The  fact  that  in  some  instances  several  cases  of  this 
rare  disease  have  occurred  in  the  same  family.  Hypertrophic 
biliary  cirrhosis  not  infrequently  occurs  in  several  members 
of  the  same  family,  and  has  been  thought  by  Boix  to  be  a 
water-borne  disease.  Against  this  view  that  so-called  con- 
genital obliteration  of  the  bile-ducts  is  in  reality  a  form  of 
congenital  cirrhosis,  it  might  with  reason  be  objected  that 
the  poison  that  sets  up  the  change  must  pass  through  the 
mother,  and  that  she  should  show  evidence  of  its  influence. 
It  must  be  admitted  that  there  are  at  present  no  data  to 
provide  a  satisfactory  answer  to  this  argument.     As  bearing 


PLATE  VI. 
Congenital  absence  of  th«  C 


• 


Fig.  24. 
(No.  1,390,  Guy's  Museum.) 


/ 


Fig.  25. —Obliteration  of  Gall-bladder  and  Common  Duct,  the 
Result  of  Gall-stone  Irritation. 


To  face  p.  74.] 


(No.  1,391,  College  of  Surgeons  Museum.) 


IN  FLA  MM  A  TOR  Y  A  FFECTIOXS  7  5 

on  this  point,  however,  it  may  be  mentioned  that  the  ex- 
tremely fatal  biliary  cirrhosis  in  Brahmin  infants  around 
Calcutta,  which  is  also  a  family  disease,  has  been  thought  to 
depend  on  the  mother's  milk.  The  mothers  restrict  them- 
selves to  a  dry  diet  and  take  a  decoction  of  black  pepper. 
If  this  is  the  causal  factor,  it  evidently  affects  the  nurslings 
more  than  the  nurses,  and  might  justify  the  suggestion  that 
in  foetal  life  the  infant's  liver  may  be  more  susceptible  than 
the  mother  to  poisons  tending  to  produce  cirrhosis,  while 
again  the  effects  of  syphilis  may  be,  and  usually  are,  much 
more  manifest  in  the  infant  than  in  the  syphilized  mother. 

To  sum  up,  it  seems  reasonable  to  believe  that  the  disease 
is  primarily  started  by  the  poisons  derived  from  the  mother 
and  conveyed  to  the  liver  of  the  foetus,  and  that  a  mixed 
cirrhosis  and  cholangitis  are  thus  set  up.  The  cholangitis 
accounts  for  the  jaundice,  and  by  descending  to  the  larger 
extrahepatic  bile-ducts  induces  an  obliterative  cholangitis 
analogous  to  obliterative  appendicitis. 

In  some  cases,  especially  those  fatal  early  in  life,  the 
latter  change  has  not  been  effected,  and  cirrhosis  alone  is 
found.  Possibly  in  some  instances  this  change  never  occurs, 
and  in  this  way  some  of  the  cases  of  cirrhosis  in  very  early 
life  are  accounted  for.  Again,  in  exceptional  instances  the 
obliterative  cholangitis  might  possibly  be  delayed,  and  come 
on  much  later ;  such  an  event  might  bring  Treves's  case, 
already  referred  to,  into  line  with  the  others. 

It  is  possible  that  there  are  several  conditions  at  present 
included  under  the  title  congenital  obliteration  of  the  ducts, 
and  that  some,  as  Dr.  Ross's  case,  are  due  to  constriction  of 
the  duct  by  localized  peritonitis,  and  deserve  the  title  better 
than  those  cases  that  are  intimately  associated  with 
cirrhosis. 

CROUPOUS  INFLAMMATION  OF  THE  GALL-BLADDER  AND 

BILE-DUCTS. 

It  had  been  noticed  as  far  back  as  1820  by  Dr.  Richard 
Powell  {Medical  Transactions  of  the  College  of  Physicians) 
that  membranous  or  croupous  enteritis  was  frequently 
associated  with  attacks  simulating  gall-stone  seizures  ;  and 


76     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Mr.  Jonathan  Hutchinson,  in  his  '  Archives  of  Surgery,'  in 
commenting  on  this  paper,  suggests  that  in  some  of  these 
cases  a  bond-fide  attack  of  gall-stone  colic  may  have  been 
the  cause  of  the  membranous  enteritis. 

From  a  number  of  cases  that  we  have  seen  and  observed, 
some  of  them  having  been  submitted  to  operation  without 
finding  gall-stones,  but  where  there  was  abundant  evidence 
of  inflammation  of  the  gall-bladder  and  bile-ducts,  we  have 
formed  the  opinion  that  the  cause  of  the  painful  attacks, 
followed  by  slight  jaundice  in  these  cases  of  membranous 
enteritis,  is  the  formation  of  membrane  in  the  bile  passages, 
which,  partly  obstructing  the  bile  flow,  sets  up  spasm  of  the 
gall-bladder,  just  as  a  gall-stone  or  even  a  lump  of  tenacious 
mucus  will  do,  as  shown  in  the  cases  mentioned  in  the 
chapter  on  chronic  catarrh  of  the  gall-bladder,  where 
operation  was  undertaken  for,  and  led  to  the  cure  of, 
attacks  of  pain  dependent  on  chronic  catarrhal  chole- 
cystitis. 

Owing  to  the  disintegrating  effect  of  the  bile  and  of  the 
intestinal  secretion,  it  seldom  happens  that  a  true  cast  of 
the  gall-bladder  or  bile-ducts  is  discovered,  as  occurred  in 
the  following  case  related  by  Dr.  Clennell  Fenwick*  of 
Christchurch,  New  Zealand,  concerning  a  patient  he  had 
seen  with  Dr.  Brittin. 

'  A.  B.,  aged  twenty-nine,  has  had  nine  attacks  of  biliary 
colic  in  the  last  fourteen  months,  accompanied  by  more  or  less 
severe  jaundice.  During  the  first  two  attacks  he  passed  on 
each  occasion  a  fairly  large  faceted  gall-stone.  The  fasces 
had  not  been  examined  during  the  later  illnesses ;  but  from 
the  severe  pain  and  the  symptoms,  exactly  resembling  his 
earlier  attacks,  he  feels  sure  that  he  has  passed  a  stone  on 
each  occasion.  Fourteen  days  ago  he  had  a  severe  colic, 
necessitating  the  use  of  morphine,  and  next  day  passed  a 
large  piece  of  flesh,  which  was  examined  by  his  doctor,  who 
describes  it  as  an  oblong  sac  with  moderately  thick  walls, 
stained  green,  about  2  inches  long  and  I  inch  broad,  re- 
sembling the  gall-bladder  in  shape.  Ten  days  later  he  was 
again  seized  with  severe  pain,  similar  to  that  experienced  in 
*  British  Medical  Journal,  April  23,  1898. 


INFLAMMATORY  AFFECTIONS  77 

all  the  former  illnesses,  and  after  some  hours  of  agony  he  was 
relieved,  and  next  passed  another  cast,  which  I  examined. 
It  is  2  inches  long,  and  ij  inches  in  breadth,  its  walls 
are  -^(J  inch  thick;  it  is  a  closed  sac  with  a  distinct 
neck,  and  is  stained  bright  green  in  parts,  especially  towards 
the  neck.  When  laid  out  it  appears  to  resemble  a  gall- 
bladder. The  accompaning  faeces  were  clay-coloured,  and 
had  been  so  for  a  long  period  of  time.  There  was  no  micro- 
scopic appearance  of  hydatid  structure,  and  I  do  not  think 
that  it  was  an  intestinal  cast.  We  came  to  the  conclusion 
that  both  these  casts  were  derived  from  the  gall-bladder,  as 
the  patient  had  suffered  from  typical  biliary  colic  many  times 
before,  and  described  the  pain  experienced  before  the  passage 
of  the  casts  as  exactly  similar  to  that  he  had  felt  before  he 
passed  the  gall-stones. 

'  It  does  not  seem  improbable  that  the  presence  of  the 
stones  had  set  up  a  chronic  inflammation  in  the  bladder 
which  had  resulted  in  the  formation  of  a  false  membrane, 
which  had  itself  been  expelled  after  the  last  stone  had  been 
passed.' 

Dr.  Powell,  in  the  paper  referred  to,  describes  the  symp- 
toms as  follows : 

'  The  more  violent  seizures  under  which  I  saw  all  the 
patients  consisted  in  a  sudden  and  excessive  pain  in  the 
epigastric  region,  coming  on  in  paroxysms  very  frequently 
repeated,  rather  relieved  by  the  pressure  of  the  patient  herself 
at  the  time,  but  leaving  great  soreness  and  tenderness  during 
the  intervals.  This  state  continued  for  about  four  days,  and 
during  the  attack  the  stomach  was  very  irritable  and  the 
tongue  coated  and  clammy.  Jaundice  came  on  at  an  early 
period,  and  the  stools  were  white,  brown,  or  somewhat 
greenish,  and  streaked  in  colours,  until  the  films  began  to 
pass,  when  they  were  mixed  with  a  full  quantity  of  bile,  but 
not  at  first  of  a  healthy  colour.' 

Dr.  Powell  further  remarks  : 

1  The  formation  of  adventitious  membrane  has  not  been 
so  frequently  observed  in  the  intestinal  canal  as  it  has  in 
circumscribed  cavities,  and  I  know  not  that  any  description 
of  the  symptoms  accompanying  such  a  state  has  heretofore 


78     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

been  given.  The  appearance  which  comes  nearest  to  it,  both 
in  resemblance  and  situation,  is  the  membrane  formed  in 
the  trachea  under  croup,  but  the  symptoms  are  there  more 
violent  and  destructive  from  locality  of  situation. 

'  Whenever  violent  pain  takes  place  in  the  epigastric  region 
of  the  abdomen,  exacerbating  in  paroxysms,  accompanied  by 
sickness,  yellowness  of  the  eyes,  skin,  and  urine,  by  clay- 
coloured  faeces,  and  without  any  proportionate  increase  of 
action  in  the  circulation,  biliary  concretions  are  supposed 
to  be  forcing  their  way  through  the  ducts,  and  when  these 
symptoms  abate  it  is  inferred  that  their  passage  into  the 
duodenum  has  been  effected.' 

After  this  Dr.  Powell  proceeds  to  state  that  he  has  often 
been  disappointed  in  not  finding  a  gall-stone  in  the  faeces, 
and  has  found  instead  what  he  proceeds  to  describe  : 

'  In  the  cases  to  which  I  refer  this  residue  has  exhibited 
a  large  quantity  of  flakes,  mostly  torn  into  irregular  shapes 
and  appearing  to  have  formed  parts  of  an  extensive  adven- 
titious membrane  of  no  great  tenacity  or  firmness.  In  the 
first  of  the  cases  which  came  under  my  notice,  this  mem- 
brane was  passed  in  perfect  tubes,  some  of  them  full  half  a 
yard  in  length,  and  certainly  sufficient  in  quantity  to  have 
lined  the  whole  intestinal  canal.  In  the  others  also  the 
aggregate  quantity  has  been  very  large,  and  it  has  continued 
to  come  away  for  many  days  ;  but  it  has  been  in  irregular 
thin  flakes  of  not  more  than  2  inches  extent,  and  not,  as  far 
as  I  could  discover,  of  the  perfect  tubular  form  (which 
would  probably  also  have  been  broken  down  by  the  agitation 
in  water,  if  it  had  existed  on  its  first  passage  out  of  the  body). 

1  I  have  definitely  examined  four  such  cases,  in  all  of  whom 
the  leading  symptoms  have  been  similar,  and  these  have  led 
me  to  suspect  the  passage  of  biliary  concretions  at  the  time. 
They  have  all  been  adult  females,  and  have  occurred  in 
private  practice.  I  had  attended  but  one  of  these  previous 
to  this  particular  attack,  and  she  had  frequently  suffered 
from  occasional  pain  in  the  intestines  and  derangement  of 
her  powers  of  digestion,  with  flatulence  and  a  sense  of  suffoca- 
tion. She  was  always  relieved  at  the  time  by  mild  opening 
medicine,  and  believed  herself  able  to  prevent  the  attacks.' 


INFLAMMATORY  AFFECTIONS  79 

It  is,  of  course,  possible  to  have  membranous  enteritis  and 
colitis  without  the  bile  channels  participating  ;  but  when  the 
combination  of  symptoms  previously  mentioned  does  occur, 
there  can  be  little  doubt  that  the  bile-passages  have  become 
involved  in  the  inflammatory  process,  and  under  these  cir- 
cumstances the  symptoms  will  demand  treatment. 

Diagnosis. — As  the  symptoms  so  exactly  resemble  gall- 
stone attacks,  the  disease  can  only  be  differentiated  by 
an  examination  of  the  evacuations,  when  the  discovery 
of  membranous  intestinal  casts  will  raise  the  suspicion  of 
croupous  cholecystitis  or  choledochitis.  Should  a  cast  of 
the  gall-bladder  be  discovered,  the  diagnosis  will  be  rendered 
certain,  but  in  the  absence  of  such  positive  evidence  the 
possibility  of  gall-stones  being  also  present  will  be  enter- 
tained. 

In  Case  166,  the  patient,  a  man,  aged  thirty-six,  had  suf- 
fered from  attacks  of  paroxysmal  pain  in  the  upper  abdomen 
which  exactly  simulated  biliary  colic.  No  gall-stones  had 
been  found  in  the  motions ;  but  for  some  time  before  opera- 
tion membranous  casts  had  been  found  in  the  stools  after 
his  attacks  of  colic.  When  examined,  no  tumour  could  be 
made  out,  but  the  right  rectus  was  rigid  in  its  upper  half. 
At  the  operation  no  gall-stones  were  found,  but  there  were 
adhesions  of  the  gall-bladder  to  the  omentum,  duodenum, 
and  colon,  which,  in  association  with  the  catarrh  of  the  bile 
passages,  was  quite  sufficient  to  account  for  the  attacks 
simulating  gall-stones.  The  patient  was  cured  by  the  opera- 
tion, and  some  time  later  was  quite  well,  and  so  far  as  the 
gall-bladder  seizures  are  concerned,  he  is  well  at  the  present 
time,  though  there  have  recently  been  symptoms  of  mem- 
branous colitis. 

Case  215  was  of  a  somewhat  similar  character,  but  in  it 
there  was  associated  cholelithiasis.  The  patient  was  a  woman, 
aged  forty-seven,  and  her  first  attack  of  gall-stone  colic  had 
occurred  about  two  years  before  operation.  Similar  seizures 
took  place  frequently,  gradually  increasing  in  intensity  and 
lasting  longer.  Towards  the  end  of  her  illness  membranous 
casts  were  found  in  the  motions. 

On  examination,  there  was  the  usual  local  tenderness,  and 


80     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

the  gall-bladder  could  be  felt  to  be  slightly  enlarged.  At 
the  operation  there  were  found  seventy-eight  stones  in  the 
gall-bladder,  cystic  and  common  ducts,  and  numerous 
adhesions. 

Treatment. — If  under  treatment  by  saline  aperients,  such 
as  Carlsbad  salts  given  the  first  thing  in  the  morning  and 
careful  dieting,  the  symptoms  do  not  abate,  the  question  of 
drainage  of  the  gall-bladder  by  cholecystotomy  will  be  well 
worth  considering  (as  in  Case  215),  and  at  the  time  of 
operation  adhesions  of  the  gall-bladder  to  the  neighbouring 
viscera,  which  will  probably  be  found,  should  be  broken 
down  (as  in  Case  166). 

In  both  cases  referred  to  operation  was  followed  by  marked 
relief,  and  by  entire  cessation  of  the  attacks  resembling 
cholelithic  seizures,  though  in  Case  166,  after  a  year  and  a 
half,  there  was  a  repetition  of  intestinal  colic,  followed  by 
the  passage  of  some  membrane  in  the  fasces,  the  attack 
coming  on  as  a  result  of  exposure  to  cold  and  wet  along  with 
irregularities  in  diet  ;  but  with  the  intestinal  colic  it  is  inter- 
esting to  note  that  there  was  none  of  the  old  biliary  colic. 


SUPPURATIVE  INFLAMMATION   OF  THE  BILE  PASSAGES, 
AND  ITS  RELATION  TO  MICRO-ORGANISMS. 

Suppurative  Inflammation  of  the  Bile  Passages. 

At  first  sight  suppurative  inflammation  of  the  gall-bladder 
and  bile-ducts  would  seem  to  be  capable  of  description  in 
small  compass  and  under  one  heading,  but  the  subject  is  by 
no  means  so  simple  as  it  would  appear. 

For  instance,  simple  empyema  or  suppurative  catarrh  of 
the  gall-bladder,  which  is  closely  allied  to  suppurative 
cholangitis,  differs  markedly  in  its  clinical  characters  from 
phlegmonous  cholecystitis,  which,  however,  is  also  associated 
with  pus  in  the  gall-bladder,  that  may  quite  properly  be  called 
an  empyema,  but  which  is  one  of  the  most  fatal  of  diseases  if 
not  operated  on  expeditiously,  as  not  only  is  there  a  tendency 
to  gangrene,  but  to  a  rapidly-spreading  lethal  peritonitis. 

The  different  clinical  characters  of  suppurative  inrlamma- 


IX  FLA  MM  A  TORY  AFFECTIONS  8r 

tion  can  probably  be  accounted  for  by  the  presence  or  absence 
of  certain  organisms. 

It  has  been  supposed  that  the  bile  is  an  antiseptic  fluid, 
which  tends  to  prevent  decomposition  in  the  alimentary 
canal  ;  but  in  a  series  of  observations*  published  some  years 
ago  on  a  case  of  biliary  fistula  it  was  noted  that  the  absence 
of  bile  from  the  intestine  of  a  woman  during  a  period  of 
fifteen  months  did  not  lead  to  any  irregular  fermentative 
process,  showing  that  the  alleged  antiseptic  effect  of  bile  on 
the  faeces  is  probably  imaginary. 

Normal  bile  is,  however,  generally  sterile.  This  was  proved 
in  1884  by  Netter,t  who  experimented  on  dogs  ;  and  the  fact 
has  been  confirmed  by  Gilbert  and  Girode,*  and  later  by 
Naunyn,§  who  found  it  sterile  in  two  cases  within  a  few 
hours  of  death.  We  have  also  found  normal  bile  to  be  sterile 
in  the  human  subject. 

Frequent  inoculation  experiments  on  animals  have  con- 
firmed these  observations,  thus  explaining  a  well-known  fact 
that  in  many  cases  bile  has  been  extensively  poured  out  into 
the  peritoneal  cavity  without  setting  up  peritonitis ;  but  the 
fact  of  healthy  bile  doing  no  harm  for  a  time  must  not  lead 
operators  to  be  careless  of  extravasation  when  operating  for 
disease  of  the  gall-bladder  or  bile-ducts,  as  in  such  cases  the 
bile  is  seldom  or  never  sterile,  and  in  that  condition  it  is 
capable  of  producing  severe  peritonitis. 

In  a  case  of  mucous  fistula  following  operation  for  stricture 
of  the  cystic  duct  the  constant  clean  appearance  of  the  edges 
of  the  fistula  suggested  the  idea  that  the  fluid  secreted  by  the 
gall-bladder  might  possess  antiseptic  properties  ;  and  the 
observation  that,  when  collecting  the  fluid  for  experimental 
purposes,  the  flasks  could  be  left  exposed  to  the  air  for 
several  days  without  any  apparent  change  suggested  the 
same  conclusion. 

Professor  Birch,  of  the  Yorkshire  College,  who  was  sup- 
plied by  me  with  some  of  this  fluid,  performed   numerous 

*  '  Observations  on  the  Secretion  of  Bile  in  a  case  of  Biliary  Fistula, 
by  Mayo  Robson  (Proceedings  of  the  Royal  Society,  vol.  xlvi.). 
\  Pr ogres  Medical,  1886. 
%  Comptes  Rendus,  Soc.  Biol.,  1890,  No.  39. 
§  '  Klinik  der  Cholelithiasis,'  1892. 


82     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

cultivation  experiments,  and  came  to  the  conclusion  that 
its  antiseptic  properties  were  slight,  the  want  of  change 
being  probably  due  to  poverty  of  the  fluid  in  nourishing 
materials.* 

Bloch  has  demonstrated  that  the  bile  in  case  of  disease 
of  the  gall-bladder  or  bile-ducts  always  contains  micro- 
organisms ;  hence  he  thinks  it  advisable  to  perform  chole- 
cystotomy  in  two  stages,  in  order  to  avoid  soiling  the 
peritoneum  and  producing  infective  peritonitis. 

As  will  be  shown  later  when  speaking  of  operations  for 
gall-stones,  we  consider  the  operation  a  deux  temps  unneces- 
sary, as  with  due  care  the  peritoneum  can  be  protected  from 
being  soiled  by  the  infected  bile. 

When  the  flow  of  bile  along  the  ducts  is  arrested,  micro- 
organisms often  invade  the  gall-bladder  either  from  the  blood 
or  the  intestine. 

Charcot  and  Gombaultt  demonstrated  organisms  within 
it  after  ligaturing  the  common  duct  in  dogs.  This  was  con- 
firmed by  Nettert  in  1886,  who  found  that  twenty-four  hours 
after  aseptic  ligature  of  the  common  duct  in  dogs  organisms 
(both  staphylococcus  and  B.  coli  commune)  could  be  cultivated 
from  the  bile.  In  1886  M.  Galippe  found  microbes  in  biliary 
calculi. 

Ehret  and  Stolz  (Berl.  Klin.  Woch.,  January  6,  1902)  per- 
formed several  experiments  on  dogs  to  explain  the  sudden 
occurrence  of  inflammation  in  connection  with  chronic 
cholelithiasis.  Sterilized  hollow  glass  balls  were  inserted 
into  the  gall-bladders  of  dogs.  About  three  months  after- 
wards some  of  the  animals  were  fed  on  decomposing  food. 
They  began  to  suffer  from  diarrhoea,  and  died  within  a  few 
weeks,  purulent  cholecystitis  being  found  post-mortem.  In 
another  series  of  animals  small  fragments  of  sterilized  cotton- 
wool were  inserted  into  the  gall-bladder.  Eight  to  ten 
months  afterwards  two  of  the  animals,  apparently  in  perfect 
health,  were  examined  by  laparotomy.  The  gall-bladder  was 
thickened,   and  contained  a   number  of   organisms,    chiefly 

*  Journal  of  Physiology,  No.  7. 

+  Archives  dc  Phvsiologie  ct  Pathologic,  1876  p.  455. 

\  Progres  Medical,  1886  p.  992. 


INFLAMMATORY  AFFECTIONS  83 

B.  coli.  The  other  dogs  died  in  from  eight  to  sixteen  weeks, 
and  post-mortem  suppurative  cholangitis  and  cholecystitis 
was  found.  The)'  found  that,  as  the  illness  appeared  sud- 
denly long  after  the  operation,  it  was  probably  due  to  auto- 
infection,  very  likely  from  the  intestine,  and  they  emphasize 
the  fact  of  the  temporarily  increased  virulence  of  the  B.  coli 
during  an  attack  of  diarrhoea. 

The  B.  coli  commune  exists  normally  in  the  human  body, 
and  is  said  to  be  the  most  abundant  and  most  constant  of 
the  bacteria  found  in  man  in  health.  It  has  been  demon- 
strated in  every  part  of  the  alimentary  canal,  from  the  mouth 
to  the  anus.  It  varies  greatly  in  its  virulence,  and  in  experi- 
ments on  animals  it  appears  to  be  harmless  when  taken  from 
the  normal  intestines.  If,  however,  the  intestine  or  its 
diverticula  become  the  seat  of  any  morbid  conditions,  then 
the  bacterium  becomes  at  once  virulent.  At  one  time,  as 
shown  by  Escherich,*  it  may  act  as  an  ordinary  pyogenic 
organism,  producing  local  abscesses  ;  at  another,  as  an  active 
pathogenic  germ,  producing  fatal  septicaemia. 

Nettert  found  staphylococci  and  streptococci  present  in 
pathological  human  bile,  and  Martha,  J  Gilbert  and  Girode,§ 
and  Bouchard  ||  found  the  B.  coli  commune  in  the  bile  in  cases 
of  inflammation  of  the  biliary  passages. 

Terrier  states  that  he  has  proved  organisms  (both  B.  coli 
commune  and  streptococci)  to  be  present  in  all  cases  of  in- 
flammation of  the  bile  passages.^ 

In  acute  or  phlegmonous  cholecystitis  the  walls  of  the 
gall-bladder  are  swollen  and  oedematous,  and  may  be  infil- 
trated with  pus.  In  three  out  of  five  of  such  cases  Naunyn 
found  the  B.  coli  commune  in  the  pus. 

Bonnecken,  in  1890,  demonstrated  these  organisms  in  the 
sac  of  a  strangulated  hernia,  although  there  was  no  perfora- 
tion, this  observation  having  since  been  proved  correct  over 
and  over  again. 

*  Fo7'tschritte  der  Medecin,  1885. 

\  Archives  de  Physiologie  Normale  et  Pathologique,  1886. 

j  Ibid. 

§  Comfttes  Rendu  s,  Sociele  de  Biologie,  90  and  9 1 . 

i|  Ibid.,  1890. 

\  Revue  de  Chirurgie,  1895,  p.  965. 

6—2 


84     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

All  surgeons  are  familiar  with  the  occurrence  of  suppurative 
peritonitis  in  cases  of  appendicitis,  where,  after  removal  of 
the  vermiform  appendix,  the  most  careful  examination  fails 
to  reveal  any  perforation.  Similarly,  Barbacci  has  shown 
that  peritoneal  sepsis  may  occur  by  infection  from  within 
the  intestine  without  any  direct  communication  between  its 
lumen  and  the  peritoneal  cavity.  In  both  these  cases,  how- 
ever, it  is  probable  that  there  is  always  some  amount  of 
necrosis  of  the  epithelial  lining  of  the  gut.  The  spread  of 
infection  through  the  walls  of  the  gall-bladder  can  readily 
be  explained  on  the  same  hypothesis,  showing  how  virulent 
peritonitis  may  arise  in  these  cases,  though  there  be  no 
perforation. 

Drs.  Gilbert  and  Girode*  found  typhoid  bacilli  in  the  pus 
from  a  case  of  empyema  of  the  gall-bladder,  which  came  on 
as  a  sequence  of  enteric  fever. 

Gilbert  and  Dominici  t  also  assert  that  they  produced  sup- 
puration in  the  gall-bladder  and  liver  of  rabbits  by  injecting 
a  culture  of  typhoid  bacilli  into  the  common  duct. 

Welsh  and  Blackstein  {Johns  Hopkins  Hospital  Bulletin, 
vol.  ii.,  1891)  found  typhoid  bacilli  in  the  gall-bladder  in 
cases  of  experimental  typhoid  inoculation  in  animals.  In 
one  case  the  organisms  were  discovered  in  the  gall-bladder 
on  the  128th  day  after  the  inoculation,  though  they  had 
disappeared  from  every  other  organ  in  the  body. 

Flexner  found  in  50  per  cent,  of  fatal  cases  of  typhoid 
fever  the  organisms  in  pure  culture  in  the  gall-bladder. 

These  biological  facts  are  borne  out  by  the  clinical 
observations  of  Dr.  Murchison  and  Dr.  Hale  White,  who 
found  evidence  of  inflammation  and  ulceration  in  the  gall- 
bladder in  well-marked  and  fatal  cases  of  typhoid  fever, 
there  being  no  obstruction  to  the  passage  of  bile,  or  other 
cause  than  the  specific  disease,  to  account  for  the  trouble. 

Chiari  J  investigated  systematically  a  series  of  twenty-two 
cases  of  typhoid  fever.  With  the  exception  of  three  cases — 
one  of  which  was  in  the  infiltrating,  and  two  in  the  necrotic, 

*  Biological  Society  of  Paris,  December  2,  1893. 
t  Ibid.,  December  23,  1893. 
/.nt.  f.  /Ai//,\,  Bd  15,  p.  199. 


INFLAMMATORY  AFFECTIONS  85 

stage — he  obtained  typhoid  bacilli  invariably  out  of  the  gall- 
bladder, and  in  fifteen  cases  they  were  obtained  in  pure 
culture.  They  were  generally  present  in  considerable 
numbers.  In  thirteen  of  the  nineteen  cases  in  which  a 
positive  result  was  obtained,  there  was  inflammation  of  the 
gall-bladder  with  small-celled  infiltration,  oedema,  and  hyper- 
emia. In  all  twenty-two  cases  the  diagnosis  of  typhoid 
fever  was  confirmed  by  cultivations  from  the  spleen,  mesen- 
teric glands,  or  liver,  or  from  the  larger  bile-ducts. 

How  do  bacteria  reach  the  gall-bladder  ? 

There  are  three  possibilities  :  either  they  enter  by  the 
bile-ducts,  or  from  the  blood,  or  they  reach  the  interior 
directly  through  the  wall  of  the  gall-bladder.  The  last- 
mentioned  manner  must  be  very  exceptional,  even  if  pos- 
sible. Their  entrance  from  the  blood  has  been  apparently 
proved,  but  it  is  extremely  probable  that  they  usually  enter 
by  the  bile-ducts. 

There  is  no  doubt  that  typhoid  bacilli  multiply  in  the 
gall-bladder,  and  it  is  probable  that  they  may  be  responsible 
for  post-typhoidal  cholecystitis  and  chronic  catarrh  of  the 
gall-bladder  and  bile-ducts,  as  well  as  for  the  formation  of 
gall-stones.  (See  Chapters  on  Gall-Stones  and  on  Perfora- 
tion of  the  Gail-Bladder  and  Bile-Ducts.) 

Simple  Empyema. 

Suppurative  catarrh,  or  simple  empyema,  of  the  gall- 
bladder, or  suppurative  cholecystitis,  is,  as  a  rule,  associated 
with  gall-stones ;  but  tumours  of  the  bile-ducts,  typhoid 
and  other  fevers,  and  other  unexplained  conditions,  may 
also  be  the  predisposing  factors,  though  infection  by  pyo- 
genic organisms  is  probably  in  every  case  the  true  exciting 
cause. 

Empyema  of  the  gall-bladder  must  always  be  looked  on 
as  a  serious  affection,  both  on  account  of  its  causes  and  its 
sequelae,  but  from  a  clinical  standpoint  there  is  one  form 
which  is  decidedly  less  serious  than  the  other.  The  less 
serious  will  be  discussed  first  under  the  term  '  simple 
empyema  of  the  gall-bladder  ' ;  the  more  serious  form  will 


86     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

be  considered  later  as  a  distinct  and  special  disease  under 
the  name  of  '  phlegmonous  cholecystitis.' 

When  we  bear  in  mind  Charcot  and  Gombault's  experi- 
ments on  ligature  of  the  common  duct  in  dogs,*  just  referred 
to,  the  wonder  is  that  all  impacted  gall-stones  are  not  asso- 
ciated with  empyema;  yet  such  is  not  the  case,  and  it  is  only 
in  a  certain  small  percentage  that  the  catarrh  passes  on  to 
suppuration. 

When  there  is  an  obstruction  or  any  irritation  in  the  cystic 
duct,  a  simple  empyema  may  result,  but  when  the  obstruc- 
tion is  in  the  common  duct,  it  may  be  associated  with 
infective  or  with  suppurative  cholangitis ;  the  empyema 
being  a  local  suppurative  process,  the  cholangitis  an  ex- 
tremely serious  disease,  rapidly  followed  by  general  symptoms, 
and,  unless  treated  by  operation,  usually  ending  fatally. 

In  simple  empyema  the  symptoms  will  at  first  depend  on 
the  cause,  and  as  this  is,  in  the  great  majority  of  cases, 
cholelithiasis  (Courvoisier  found  empyema  to  be  caused  by 
gall-stones  in  forty-one  out  of  fifty-five  cases),  there  will  be 
the  usual  history  of  gall-stone  seizures,  followed  by  a  swelling 
under  the  right  lobe  of  the  liver,  and  by  a  continued  instead 
of  an  intermittent  pain.  (Cases  6,  ioo,  106,  134,  151,  159, 
etc.,  are  good  examples.) 

At  first  the  constitutional  symptoms  may  be  only  slightly 
marked,  and  there  may  be  no  increase  of  temperature, 
though  in  the  later  stages,  and  in  some  from  the  com- 
mencement, rigors  or  chills  with  fever  will  point  to  the 
formation  of  pus.  The  difference  in  the  two  seems  to  be 
determined  by  the  absence  or  presence  of  ulceration  of  the 
mucous  membrane. 

The  patient  is,  as  a  rule,  driven  to  bed  at  an  early  stage 
on  account  of  the  pain  on  movement.  The  loss  of  appetite, 
fever,  and  general  malaise,  usually  lead  to  loss  of  flesh  and 
weight.  As  a  rule,  there  is  no  jaundice  or  only  a  slight 
icteric  tinge,  dependent  on  associated  catarrh  of  the  bile- 
ducts.  Tenderness  is  always  present,  in  consequence  of  the 
local  adhesive  peritonitis.  The  most  tender  spot  is  at  some 
point  in  a  line  between  the  ninth  costal  cartilage  and  the 
*  Progrfo  Mddical)  1886,  p.  996. 


INFLAMMATORY  AFFECTIONS  87 

umbilicus,  but  in  many  cases  the  tenderness  is  diffused  over 
the  right  upper  half  of  the  abdomen. 

The  tumour,  if  seen  at  an  early  stage,  will  move  with 
respiration,  descending  with  the  liver,  and  being  felt  as  a 
rounded  swelling.  After  a  time  the  swelling  may  become 
more  diffused  and  general,  and  the  movements  during 
respiration  will  be  less  marked,  or  may  cease,  owing  to 
inflammation  extending  to  the  abdominal  walls.  If  the 
suppuration  extends  beyond  the  gall-bladder,  the  pus  may 
make  its  way  through  the  parietes,  and  an  abscess  may  form 
under  the  right  costal  margin,  as  in  the  following  case. 

Case  459. — Mrs.  H.,  aged  forty-eight,  seen  with  Dr. 
Woodcock  of  Leeds,  October  11,  1902.  For  five  years  she 
had  suffered  from  attacks  of  biliary  colic.  Lately  the  pain 
had  become  more  severe  and  continuous,  and  was  accom- 
panied by  loss  of  flesh,  shivering,  and  jaundice.  During 
the  last  few  weeks  a  swelling  had  appeared  under  the  right 
costal  margin,  and  the  abdominal  wall  at  length  became 
involved.  There  was  a  large  fluctuating  swelling  in  the 
right  hypochondriac  region ;  the  skin  was  reddened  and 
cedematous. 

Operation,  October  12,  1902. —  Incision  gave  exit  to  ih 
pints  of  pus;  a  sinus  was  found  running  through  the 
abdominal  parietes  into  the  gall-bladder.  This  was  dilated, 
and  a  quantity  of  pus  and  three  gall-stones  removed  from 
the  gall-bladder.  The  gall-bladder  was  drained  and  the 
abscess  cavity  packed  with  gauze.  The  patient  made  an 
uninterrupted  recovery,  and  is  now  quite  well. 

The  pus  usually  selects  a  more  tortuous  passage,  and, 
following  the  suspensory  ligament  of  the  liver,  it  reaches  the 
umbilicus,  as  in  Case  79,  where,  in  a  lady  of  thirty-five, 
after  a  long  illness,  an  abscess  formed  at  the  umbilicus  and 
burst,  discharging  pus  and  mucus.  There  was  nothing  to 
show  the  origin  of  the  trouble  except  a  history  of  spasms  for 
years,  without  jaundice.  On  laying  open  the  fistula,  a  large 
number  of  gall-stones  were  readily  removed  from  the  gall- 
bladder.    The  patient  remains  in  good  health. 

In  Case  292  I  was  urgently  summoned  to  operate  on  a 
supposed  obstructed  and  inflamed  umbilical  hernia,  which  on 


88     DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

being  opened  was  found  to  contain  pus  and  gall-stones,  the 
evacuation  of  which,  followed  by  drainage,  led  to  cure. 

The  abscess  may  even  burst  at  a  distance  from  its  origin 
— for  instance,  over  the  pubes  or  over  the  caecum — or  it  may, 
after  setting  up  adhesions  to  adjoining  viscera,  be  discharged 
into  the  duodenum,  colon,  stomach,  or  pelvis  of  the  kidney ; 
or,  passing  into  the  liver,  it  may  lead  to  abscess  of  that  organ  ; 
or,  perforating  the  diaphragm,  it  may  discharge  into  the  pleura 
and  set  up  empyema,  or  into  the  pericardium  and  incite 
pericarditis,  or  into  the  peritoneal  cavity  and  produce  acute 
general  peritonitis. 

There  are  generally  peritoneal  adhesions  which  prevent 
extravasation  into  the  general  peritoneal  cavity  ;  but  the  pus 
may  make  its  way  into  neighbouring  organs,  as  in  Case  27, 
where  it  burrowed  into  the  liver  and  formed  an  abscess, 
which  was  evacuated  at  the  time  of  operation.  On  several 
other  occasions  I  have  found  a  cavity  in  the  liver  containing 
pus  and  gall-stones  communicating  with  the  diseased  gall- 
bladder. 

Quite  recently  I  operated  on  a  patient,  aged  twenty-six, 
who  for  several  years  had  been  coughing  up  i|  pints  of 
offensive  pus  and  bile  daily,  which  has  ceased  after  the 
removal  of  a  gall-stone  from  the  hepatic  duct.     (Case  508.) 

In  King's  College  Museum,  No.  1,706,  is  an  example  of  a 
gall-stone  which  was  removed  from  the  pleura  of  a  patient  by 
Professor  Rose,  and  as  the  patient  had  coughed  up  a  quantity 
of  bile-stained  pus,  an  empyema  of  the  gall-bladder  had 
probably  burst  through  the  pleura,  though  no  communica- 
tion could  be  discovered  after  death,  which  occurred  a  few 
weeks  after  operation. 

In  one  case  that  I  saw  with  a  colleague  a  large  subphrenic 
abscess,  caused  by  an  empyema  of  the  gall-bladder  becoming 
extravasated  between  the  liver  and  diaphragm,  was  success- 
full)'  evacuated  and  drained. 

If  we  bear  in  mind  the  pouch  of  peritoneum  in  front  of  the 
right  kidney,  it  is  not  to  be  wondered  at  that  a  collection  of 
pus  should  at  times  form  in  that  region  resembling  a  peri- 
renal abscess,  though  inside  the  peritoneum  and  limited  by 
adhesions.     (Case  212  is  an  example.) 


INFLAMMATORY  AFFECTIONS  89 

Needless  to  say,  an  abscess  of  the  gall-bladder  only  requires 
treating  on  general  surgical  principles  by  opening  and  drain- 
age ;  but,  at  the  same  time,  the  cause  must  not  be  overlooked, 
as  it  may  often  be  removed  at  the  same  time  that  the  abscess 
is  evacuated. 

Where  the  pus  is  in  the  gall-bladder,  cholecystotomy  will 
be  advisable.  After  exposing  the  gall-bladder,  it  will  be  wise 
to  aspirate  before  opening  it,  in  order  to  avoid  soiling  the 
tissues  with  pus. 

The  walls  of  the  gall-bladder  may  be  found  so  friable  as 
to  be  incapable  of  holding  sutures,  or  there  may  be  small 
abscesses  in  the  inflamed  wall  of  the  gall-bladder  itself; 
in  such  cases  cholecystectomy  may  be  required.  In  two 
cases  of  empyema  of  the  gall-bladder,  after  the  pus  had 
been  evacuated  and  the  gall-stones  removed,  the  cavity  was 
packed  with  iodoform  gauze,  and  although  the  peritoneal  sac 
was  widely  opened,  no  harm  resulted,  as  a  lymph  barrier 
was  soon  thrown  out,  limiting  the  only  partly  disinfected 
area. 

In  abscess  due  to  empyema  of  the  gall-bladder,  reaching 
the  surface  at  some  distance  from  the  seat  of  origin,  it  may 
be  wise  at  first  simply  to  open  and  drain  the  abscess,  and  on 
some  future  occasion  to  perform  cholecystotomy  or  chole- 
cystectomy. This  was  the  course  successfully  followed  in 
Case  109. 

But  it  may  be  feasible,  as  in  a  case  mentioned  above, 
after  opening  the  superficial  abscess,  to  dilate  the  fistula 
leading  to  the  gall-bladder  and  remove  the  stones,  after- 
wards leaving  a  tube  in  the  gall-bladder.  This  may  be 
effected  without  detaching  the  adherent  gall-bladder  from 
the  surface. 

In  some  cases  of  empyema  the  patient  may  not  be  in  a 
fit  condition  to  bear  a  prolonged  operation,  and  it  may  there- 
fore be  wiser  to  perform  a  simple  cholecystotomy  and  to  defer 
the  removal  of  the  cause  until  an  examination  of  the  discharge 
shows  it  to  be  sterile  or  nearlv  so. 


90    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

ACUTE  PHLEGMONOUS    CHOLECYSTITIS    AND   GANGRENE 
OF  THE  GALL-BLADDER. 

Acute  or  phlegmonous  inflammation  of  the  gall-bladder 
was  described  by  Courvoisier  in  1890,  under  the  name  of 
acute  progressive  empyema  of  the  gall-bladder,  and  he  states 
that  it  usually  terminates  fatally  in  a  few  days  from  diffuse 
peritonitis.  Only  seven  cases  are  regarded  in  Courvoisier's 
statistics. 

Potain*  also  mentions  that,  in  addition  to  the  ordinary 
variety  of  empyema  of  the  gall-bladder,  there  is  a  very  grave 
condition  of  acute  empyema,  which  is  followed  by  rapid 
peritonitis  and  death.  In  one  case,  which  he  describes, 
death  occurred  on  the  second  day  after  the  onset  of  the 
attack,  and  although  there  was  no  perforation  of  the  walls  of 
the  viscus,  infection  had  spread  through  the  coats  to  the 
general  peritoneal  cavity. 

Oslert  refers  to  it  as  an  extremely  rare  disease. 

A  case  described  by  Mr.  W.  Arbuthnot  LaneJ  affords  a 
good  example  of  phlegmonous  inflammation  simulating  acute 
intestinal  obstruction,  or  acute  pancreatitis. 

A  man,  aged  fifty-four,  was  suddenly  seized  with  abdominal 
pain  immediately  after  a  rather  hearty  meal. 

This  continued,  and  was  accompanied  by  frequent  vomit- 
ing. Next  day  the  vomiting  became  less  frequent,  and  then 
ceased  ;  ingestion  of  food,  however,  caused  much  distress 
and  renewed  vomiting. 

The  abdomen  became  much  distended,  and  both  pain  and 
distension  were  now  marked  on  the  right  side. 

These  symptoms  increased  in  severity  till  the  fourth  day 
of  the  illness,  when  Mr.  Lane  first  saw  him.  The  bowels 
had  not  moved  since  the  onset.  He  was  now  in  a  very 
prostrate  condition,  with  a  small  rapid  pulse  and  a  very  dis- 
tended, painful,  and  tender  abdomen,  the  hardness  and  ful- 
ness being  most  distinct  about  the  right  hypochondriac  region 
and  its  vicinity. 

*  Jour  Jin/  de  Mcdecinc  et  Chirur^ic,  November,  1882. 
t  '  Principles  and  Practice  of  Medicine.' 
%  Lancet.  February  25,  1893. 


INFLAMMATORY  AFFECTIONS  91 

There  was  no  previous  history  of  gall-bladder  trouble  nor 
of  intestinal  obstruction. 

From  the  distended  condition  of  the  small  intestines  and 
caecum,  with  the  collapse  of  the  colon  on  the  left  side,  the 
case  was  supposed  to  be  one  of  obstruction  about  the  hepatic 
flexure. 

On  opening  the  peritoneal  cavity,  a  very  thick  layer  of 
firm  lymph,  covering  the  edge  of  the  liver  and  extending 
down  over  the  adjacent  transverse  colon,  was  found,  beyond 
which  the  colon  was  empty,  contrasting  with  the  distended 
condition  of  the  proximal  part  of  the  bowel. 

In  immediate  relation  with  the  transverse  colon  and  the 
duodenum,  which  was  also  covered  with  lymph,  was  found  a 
tensely  distended,  livid  gall-bladder,  which  was  not  larger 
than  normal,  and  was  evidently  very  acutely  inflamed. 

The  whole  of  the  lymph  was  carefully  removed  and  the 
gall-bladder  tapped  of  its  contents,  which  consisted  of  thick 
muco-pus.  The  opening  was  then  enlarged,  a  drainage- 
tube  inserted,  and  the  margins  of  the  wound  stitched  to  the 
peritoneum.  No  gall-stone  was  discovered.  The  patient 
made  a  complete  recovery. 

In  the  Lancet,  March  2,  1895,  is  a  case  reported  by 
Mr.  Marmaduke  Sheild,  which  is  more  fully  described  under 
perforation  of  the  gall-bladder,  but  which  was  doubtless  a 
case  of  phlegmonous  cholecystitis  following  on  typhoid  fever, 
in  a  woman,  aged  thirty-one,  under  the  care  of  Dr.  Monier 
Williams. 

She  was  operated  on  on  the  fifty-first  day  of  the  disease, 
when  the  gall-bladder  was  found  to  be  rigid,  thickened,  and 
of  a  dark  plum  colour,  containing  1 J  ounces  of  thick,  offensive 
pus  ;  it  was  ulcerated  and  perforated.  The  abdomen  was 
washed  out  and  drained,  complete  recovery  ensuing. 

No.  2,806  in  the  Hunterian  Museum  is  a  case  of  typhoid 
cholecystitis,  probably  phlegmonous,  as  the  peritoneal  coat 
had  much  false  membrane  on  it  and  pus  was  found  in  the 
gall-bladder.  It  is  from  a  case  of  typhoid  fever,  in  which 
death  occurred  in  the  fourth  week. 

Case  176  is  a  good  example  of  acute  phlegmonous  chole- 
cystitis in  a  man,  aged  forty-seven,  who  had  suffered  from 


92     DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

gall-stone  attacks  for  some  years,  had  been  severely  ill  for 
six  weeks,  and  very  acutely  ill  for  six  days  before  opera- 
tion. 

The  symptoms  were  those  of  an  acute  attack  of  local 
peritonitis  in  the  region  of  the  gall-bladder,  with  fever, 
depression,  and  general  malaise,  following  on  a  severe  gall- 
stone seizure.  When  exposed,  the  gall-bladder  was  found  of 
a  dark  plum  colour,  with  one  or  two  greenish  patches  on  its 
surface.  It  contained  malodorous  pus  and  nine  gall-stones. 
The  omentum  and  adjoining  coils  of  intestine  were  coated 
with  lymph,  thus  limiting  the  inflammation  to  a  compara- 
tively small  area. 

The  concretions  were  removed  and  all  the  pus  wiped  away 
before  the  general  peritoneal  cavity  was  opened.  Under  free 
drainage  the  patient  made  an  excellent  recover)-,  and  is  now 
well. 

Another  case  (No.  194),  in  which  the  symptoms  were 
subacute  and  dependent  on  gall-stones,  illustrates  the 
intermediate  stage  between  ordinary  empyema  and  acute 
phlegmonous  cholecystitis.  The  gall-bladder  was  dark- 
coloured,  covered  with  lymph,  and  contained  offensive  pus. 
Removal  of  the  gall-stones  and  drainage  led  to  complete 
recovery,  and  the  patient  is  now  quite  well. 

Etiology. — Although  the  condition  is  usually  associated 
with  gall-stones,  acute  cholecystitis  may  arise  quite  inde- 
pendently—  in  this  way  resembling  appendicitis,  which 
may  occur  without  the  presence  of  concretions  or  foreign 
bodies. 

Typhoid  and  typhus  fevers,  cholera,  malaria,  sepsis  after 
operation,  puerperal  fever,  and  other  unknown  conditions 
may  give  rise  to  it. 

Symptoms. — Whatever  be  the  cause,  the  disease  usually 
manifests  itself  somewhat  suddenly,  with  pain  on  the  right 
side  of  the  abdomen,  rapidly  becoming  general.  A  rapid  and 
feeble  pulse,  quick  thoracic  breathing,  fever,  intense  depres- 
sion, marked  tenderness  on  pressure  (especially  over  the  right 
side  of  the  abdomen),  rapidly  developing  tympanites,  vomit- 
ing, and  an  extremely  anxious  expression  of  countenance,  are 
usually  present. 


IN  FLA  MMA  TOR  Y  A  FFECTIONS  93 

The  acute  peritonitis,  which  is  significant  of  the  disease, 
may  be  localized  at  first,  but  later  becomes  general. 

Jaundice  may  or  may  not  be  present,  and  although  an 
elevation  of  temperature  is  usual,  it  is  by  no  means  constant, 
and  affords  only  slight  assistance  in  the  diagnosis  or 
prognosis. 

If  the  disease  be  of  the  very  acute  or  gangrenous  variety, 
death  speedily  occurs;  but  if  of  the  subacute  form,  an  abscess 
may  develop  around  the  gall-bladder,  and  the  peritonitis  may 
become  localized,  the  disease  then  resembling  a  perityphlitic 
abscess  in  its  course. 

Diagnosis. — The  diagnosis  of  phlegmonous  cholecystitis 
practically  resolves  itself  into  the  diagnosis  of  the  cause  of 
acute  peritonitis,  starting  on  the  right  side  of  the  abdomen. 

Although  this  may  be  due  to  perforation  of  the  stomach 
at  or  near  the  pylorus,  to  perforation  of  the  duodenum  or 
ascending  colon,  to  perforation  of  the  gall-bladder  or  bile- 
ducts,  and  to  other  suchlike  peritoneal  catastrophes,  the 
chief  affection  fcr  which  it  is  likely  to  be  mistaken  is  acute 
appendicitis. 

In  some  cases  the  normal  descent  of  the  caecum  into  the 
right  iliac  fossa  does  not  take  place.  The  caecum  and  colon, 
with  the  appendix,  are  found  in  the  right  hypochondrium  in 
close  relation  to  the  gall-bladder.  A  few  cases  have  been 
recorded  in  which  this  relation  was  present,  and  an  attack  of 
appendicitis  led  to  the  development  of  an  abscess  beneath 
the  right  costal  margin.  Such  a  case  would  give  rise  to 
great  difficulties  in  diagnosis,  and  it  might  be  impossible  to 
say  until  the  abdomen  was  opened  whether  the  condition 
was  due  to  gall-bladder  trouble  or  to  appendicitis.  In 
appendicitis  the  pain  usually  begins  around  the  umbilicus, 
and  is  subsequently  referred  to  the  right  iliac  fossa,  or  it  may 
start  at  a  lower  point  in  the  abdomen  and  pass  towards  the 
umbilicus  ;  whereas  in  gall-bladder  trouble  it  begins  below 
the  right  costal  margin,  and  passes  towards  the  epigastrium 
and  back  to  the  right  scapular  region. 

In  gall-bladder  inflammations  there  is  almost  invariably 
a  tender  spot  a  little  above  and  to  the  right  of  the  umbilicus, 
or,  to    be    more   exact,  at   the  junction   of  the   upper  two- 


94     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

thirds  with  the  lower  third  of  a  line  drawn  from  the  ninth 
rib  to  the  umbilicus,  or  it  may  be  all  along  this  line  or  at 
any  point  of  it,  though  at  the  point  named  it  is  the  most 
frequent. 

It  will  be  found  that  this  point  is  tender  both  to  touch 
and  to  pressure,  it  being  in  reality  the  site  of  a  reflected  pain 
passing  along  the  splanchnic  to  the  eighth  and  ninth  right 
dorsal  nerves,  and  thence  reflected  to  the  surface  termination 
of  these  nerves.  Even  when  the  gall-bladder  is  displaced, 
owing  to  deformity  or  enlargement  of  the  liver,  so  that  it  is 
placed  at  a  distance  from  its  usual  position,  I  have  found  this 
spot  to  be  tender  on  pressure,  thus  affording  a  valuable  means 
of  diagnosis. 

As  a  rule,  besides  this  point  of  tenderness,  a  peculiar 
sickening  pain  will  be  felt  on  direct  deep  pressure  over  the 
gall-bladder  itself,  usually  just  below  the  right  costal  margin, 
but  in  case  of  displacement  of  the  gall-bladder  the  pain  on 
deep  pressure  may  be  as  low  as  the  iliac  fossa. 

When  gall-stones  are  in  the  common  duct,  the  pain  on 
deep  pressure  is  generally  above  the  umbilicus,  nearer  to  or 
even  in  the  mid-line. 

In  appendicitis  there  is  in  the  same  way  a  tender  spot  at 
the  junction  of  the  outer  third  with  the  inner  two-thirds  of  a 
line  drawn  from  the  umbilicus  to  the  anterior  superior  spine 
of  the  ilium,  known  as  McBurney's  point. 

The  symptoms  of  acute  peritonitis  and  paralytic  obstruc- 
tion of  the  bowels  are  common  to  both.  Fortunately,  the 
treatment  by  exploratory  incision  is  appropriate  to  both  ; 
but  it  is  important  to  distinguish  between  them,  as  if  the 
incision  is  made  over  the  gall-bladder  in  a  case  of  appendi- 
citis, or  vice  versa,  an  abscess  may  be  opened  through  the 
unaffected  peritoneum,  and  give  rise  to  general  peritonitis. 

Treatment. — Relief  of  pain  by  subcutaneous  injections  of 
morphia  will  probably  always  be  demanded  as  a  primary 
measure,  and  as  it  is  often  impossible  to  make  a  diagnosis 
of  the  serious  condition  within  the  first  few  hours,  warm 
applications  should  be  used,  and  absolute  rest  enjoined,  all 
feeding  by  the  mouth  being  stopped,  and  the  relief  of 
symptoms  as  they  arise  being  attended  to ;  but  as  soon  as 


INFLAMMATORY  AFFECTIONS  95 

the  diagnosis  of  phlegmonous  cholecystitis  can  be  estab- 
lished, and  it  is  found  that  the  patient  is  getting  worse,  an 
exploratory  incision  should  be  made,  and  the  gall-bladder 
incised  and  drained,  the  cause,  if  found,  being  removed. 

If,  however,  gangrene  be  discovered,  the  gall-bladder  should 
be  excised,  the  indications  for  that  measure  being  as  distinct 
as  in  the  case  of  a  gangrenous  vermiform  appendix. 

If,  in  the  subacute  cases,  the  inflammation  becomes 
localized,  and  a  swelling  with  tenderness  be  found  beneath 
the  right  costal  margin,  incision  and  drainage  is  called  for, 
when  at  the  same  time  cholecystotomy  may  be  performed, 
and  if  gall-stones  be  present  in  the  gall-bladder  or  ducts, 
they  may  be  removed.  If  the  patient  be  too  ill  to  bear  a 
prolonged  operation,  the  latter  procedure  may  be  left  to 
a  subsequent  occasion. 

Gangrene  of  the  Gall-bladder  is  an  extreme  degree  of 
phlegmonous  cholecystitis. 

The  comparative  frequency  of  gangrene  in  the  vermiform 
appendix  might  lead  one  to  suppose  that  gangrenous  inflam- 
mation of  the  gall-bladder  would  not  be  uncommon  ;  yet  it 
is  apparently  rarely  seen,  the  case  reported  by  Dr.  L.  W. 
Hotchkiss  in  the  Annals  of  Surgery,  February,  1894,  being 
the  earliest  operation  for  gangrene  of  which  we  can  find  any 
record. 

Case  176,  mentioned  on  page  91,  is  an  instance  of 
phlegmonous  cholecystitis  passing  on  to  gangrene. 

Since  the  publication  of  the  last  edition  of  this  work  I 
have  operated  on  a  well-marked  case  of  gangrene  of  the 
gall-bladder. 

Case  299. — Mr.  M.  A.,  aged  fifty,  seen  with  Dr.  Tempest 
Anderson  of  York,  January  10,  1900,  for  acute  local  peri- 
tonitis of  a  week's  duration,  starting  in  the  region  of  the 
gall-bladder,  and  ushered  in  by  a  rigor,  followed  by  fever  and 
intense  pain  and  prostration,  the  first  symptom  of  pain  in 
the  gall-bladder  region  having  only  been  noticed  a  month 
previously. 

The  operation  was  performed  on  January  10,  1900,  when 
gangrene  of  the  fundus  of  the  gall-bladder  was  discovered, 
with   intense   local  peritonitis,  limited   by   acutely   inflamed 


96     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

and  darkened  omentum,  the  patient  being  a  very  fat  subject. 
Cholecystectomy  performed;  the  portion  of  gall-bladder 
attached  to  the  liver  was  left,  as  it  was  not  gangrenous ;  a 
tube  was  inserted  into  the  cystic  duct.  He  made  an  unin- 
terrupted recovery,  and  is  now  in  excellent  health. 

In  Guy's  Hospital  Museum  there  is  a  well-marked  speci- 
men of  gangrene  of  the  gall-bladder  (No.  1,397).  The 
mucous  membrane  is  dark  brown,  and  there  are  gangrenous 
patches  on  the  serous  surface.  The  common  duct  was 
obstructed  by  growth,  and  the  patient,  who  had  been  under 
the  care  of  Dr.  Moxon,  had  been  jaundiced  for  three 
months. 

In  Dr.  Hotchkiss's  case,  a  boy,  aged  nineteen,  was  ad- 
mitted to  the  Belle  Vue  Hospital,  New  York,  with  acute 
peritonitis,  which  had  come  on  suddenly,  and  was  thought 
to  be  due  to  appendicitis,  as  the  pain  was  most  severe 
over  the  csecal  region.  No  previous  history  of  gall-stones 
was  obtainable. 

Exploration  of  the  abdomen  revealed  a  tumour  of  purplish 
hue,  very  tense,  and  markedly  congested.  Some  pus  was 
found  on  its  outer  side,  and  within  it  thin,  sticky  fluid 
of  a  yellowish-brown  colour,  together  with  a  number  of 
gall-stones.  The  lower  end  of  the  gall-bladder  was  almost 
black,  and  its  walls  extremely  thin  and  apparently  gan- 
grenous. 

Death  occurred  seven  hours  after  the  operation,  and  thirty- 
four  hours  after  the  onset  of  the  attack,  the  vomiting,  rapid 
pulse,  and  high  temperature  continuing  to  the  end. 

In  order  to  explain  the  occurrence  of  gangrene,  three 
factors  have  to  be  borne  in  mind  : 

(a)  Thrombosis  of  the  nutrient  vessels. 

(6)   Bacterial  infection. 

(c)    Absence  of  drainage  (and  therefore  tension). 

The  two  latter  are  present  in  both  gall-bladder  and  appendix 
inflammation,  but  the  first  factor  is  more  frequent  in  the 
vermiform  appendix,  which  is  only  supplied  by  one  nutrient 
artery,  whereas  the  gall-bladder  has  a  very  free  blood-supply, 
not  only  through  the  branches  of  the  cystic  artery,  but  also 


IN  FLA  MM  A  TOR  Y  A  FFECTIONS  97 

through  their  anastomoses  with  the  hepatic  vessels,  where 
the  gall-bladder  is  fixed  to  the  liver. 

In  Dr.  Hotchkiss's  case  there  was  an  abnormal  circular 
constriction  of  the  gall-bladder  with  lymph  infiltration,  which 
was  apparently  sufficient  to  cut  off  the  blood-supply  from  the 
extremity  of  the  gall-bladder. 

In  my  own  cases  the  intensity  of  the  infective  process 
apparently  accounted  for  the  gangrene,  as  there  appeared  to 
be  no  unusual  constriction  in  the  gall-bladder  itself,  and  in 
one  case  not  even  gall-stones  were  present,  the  cause  of  the 
inflammation  not  being  apparent. 

INFECTIVE  CHOLANGITIS. 

Infective  cholangitis,  or  infective  catarrh  of  the  bile-ducts, 
was  first  described  by  Charcot  under  the  name  of  inter- 
mittent hepatic  fever.  It  is  usually  due  to  gall-stones  in 
the  common  duct,  which  favour  the  entrance  of  organisms 
from  the  intestine  through  the  duodenal  orifice ;  but  any- 
thing causing  obstruction  of  the  common  or  hepatic  ducts 
may  lead  to  infection  of  the  retained  bile.  Thus,  I  have 
known  infective  cholangitis  to  follow  on  chronic  pancreatitis, 
cancer  of  the  pancreas,  cancer  of  the  common  bile-duct, 
hydatid  disease,  lumbrici  in  the  bile-duct,  pancreatic  calculus 
and  stricture  of  the  common  duct,  besides  general  ailments 
such  as  typhoid  fever  and  influenza. 

Courvoisier,  Osier,  and  Fenger  have  each  described  the 
ball-valve  action  of  gall-stones  in  a  dilated  common  bile- 
duct,  thus  accounting  for  the  intermittent  character  of  the 
jaundice  and  the  irregular  course  of  the  disease. 

Although  this  condition,  in  which  the  gall-stones  are  freely 
movable  or  even  floating  in  the  common  duct,  does  give  rise 
very  frequently  to  infection  of  the  bile-ducts,  the  fixed  con- 
cretions, single  or  multiple,  are,  in  our  experience,  equallv 
potent  in  setting  up  infection,  for  in  the  latter  case  ulceration 
is  frequently  associated. 

The  usual  history  is  one  of  '  spasms  '  for  several  years, 
without  jaundice ;  then  comes  a  more  severe  seizure,  followed 
by  temporary  icterus.     If  the  gall-stone  passes,  there  is  an 

7 


I 


98     DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

end  of  the  trouble ;  but  if  not,  the  next  attack  of  pain  is 
probably  immediately  followed  by  a  shiver,  and  by  all  the 
symptoms  of  an  '  ague  fit,'  the  temperature  frequently  reach- 
ing 1040  or  1050  F.  After  it  has  passed  off,  the  skin  is  more 
deeply  tinged,  and  the  jaundice  may  persist,  though  it  varies 
in  degree ;  it  rarely,  however,  completely  disappears  between 
the  attacks,  there  being  usually  a  slight  icteric  tinge  of  the 
conjunctiva;,  even  though  the  interval  between  the  attacks 
may  be  one  of  weeks  or  months.  The  rigors  may  be  repeated 
daily,  or  at  irregular  intervals. 

The  gall-bladder  may  be  felt  as  an  enlargement  below  the 
right  costal  margin ;  but  this  is  not  usual,  as  where  there 
are  gall-stones  it  is  more  common  to  find  the  gall-bladder 
contracted.  The  liver  at  first  is  not  enlarged,  but  later  its 
lower  margin  may  descend  considerably. 

Tenderness  over  the  gall-bladder  or  in  the  epigastric  region 
can  generally  be  elicited.  There  is  usually  well-marked  loss 
of  flesh  and  strength,  and  if  unrelieved  by  Nature  or  art, 
the  disease  may  run  on  into  suppurative  cholangitis  and  its 
complications. 

Infective  cholangitis  may  persist  off  and  on  for  years,  and 
may  end  in  recovery ;  but,  on  the  other  hand,  it  may  assume 
an  acute  form,  and  lead  to  death  from  pain,  biliary  toxaemia, 
and  exhaustion.  The  complications  which  may  follow  are 
suppurative  cholangitis,  diffuse  hepatitis,  abscess  of  the  liver, 
cirrhosis  of  the  liver,  pylephlebitis,  cholecystitis  and  empyema 
of  the  gall-bladder,  perforation  of  the  ducts,  acute,  subacute, 
or  chronic  pancreatitis,  endocarditis,  pleurisy,  pneumonia, 
and  other  septic  diseases. 

Diagnosis. — Ague,  being  rare  in  England,  is  not  so  readily 
thought  of  as  it  is  in  countries  where  malaria  is  endemic  ; 
but  the  regularity  of  the  chills,  and  the  slight  jaundice  and 
enlargement  of  the  spleen  in  some  cases,  will  usually  suggest 
it,  though  the  pain  and  tenderness,  the  history  of  chole- 
lithiasis, and  the  absence  of  relief  by  large  doses  of  quinine, 
soon  settle  the  doubt.  As  infective  diseases  in  the  bile 
passages  are  prone  to  end  in  suppuration,  abscess  of  the 
liver  and  suppurative  cholangitis  may  supervene;  but  the 
more  prolonged  course  of  infective  cholangitis,  the  compara- 


INFLAMMATORY  AFFECTIONS  99 

tive  good  health  between  the  attacks,  the  irregularity  in  the 
course  of  the  disease,  and  the  absence  of  rapid  and  pro- 
gressive deterioration  of  health,  will  usually  enable  a 
diagnosis  to  be  made,  though  the  loss  of  flesh  may  be 
remarkably  rapid,  especially  if  the  pancreas  becomes  in- 
volved. When  suppuration  exists,  there  are  usually  increased 
tenderness  over  the  liver  area,  continued  or  irregular  inter- 
mitted fever,  and  intense  and  persistent  jaundice. 

The  following  cases  afford  examples  of  infective  cholangitis 
caused  by  gall-stones. 

Case  411. — Mr.  W.,  aged  sixty-one,  seen  with  Dr.  Clampitt, 
of  Bootle.  For  ten  years  subject  to  attacks  of  biliary  colic, 
which  lately  had  become  more  frequent  and  associated  with 
ague-like  attacks,  with  distinct  jaundice  and  loss  of  flesh. 
Jaundice  well-marked  after  each  attack,  but  diminished  in 
the  intervals.  No  enlargement  or  tenderness  of  the  liver, 
or  gall-bladder  could  be  felt. 

Operation,  January  20,  1902. — Choledochotomy  :  one  gall- 
stone removed  from  the  ampulla  of  Vater.  Cholecystotomy 
for  drainage. 

Patient  made  a  good  recovery,  and  in  June,  1902,  had 
gained  i\  stones  in  weight. 

Case  410. — Mrs.  G.,  aged  forty-four,  seen  with  Dr.  Wilson 
Smith,  of  Bath,  for  attacks  of  biliary  colic  off  and  on  for 
several  years.  During  the  last  six  weeks  she  had  had  several 
attacks,  associated  with  jaundice,  shivering,  and  loss  of  flesh. 
On  examination,  no  enlargement  of  the  liver  or  gall-bladder 
could  be  found.     Mitral  disease  and  albuminuria. 

Operation,  January  17,  1902. — One  stone  in  ampulla  of 
Vater  removed  by  choledochotomy.  Cholecystotomy  per- 
formed for  drainage  of  bile-ducts. 

Patient  recovered,  and,  so  far  as  the  abdomen  is  concerned, 
is  now  quite  well. 

Case  417.  —  Mrs.  D.,  aged  forty-four,  seen  with  Dr. 
Temperley  Grey,  of  Lenham.  Two  years  ago  patient  had  an 
attack  of  biliary  colic,  and  was  ill  for  some  time.  She  had 
had  numerous  attacks  since,  usually  associated  with  rigors  and 
fever,  and  one  very  severe  a  month  ago  associated  with  deep 
jaundice,  which  persisted.     No  enlargement  of  liver  or  gall- 

7—2 


I 


ioo    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

bladder ;  some  tenderness  on  deep  pressure  could  be  felt  to 
the  right  of  and  above  the  umbilicus.     Great  loss  of  flesh. 

Operation,  February  19,  1902. — Duodeno-choledochotomy  : 
one  gall-stone  removed  from  the  ampulla  of  Vater.  One 
stone  removed  from  gall-bladder  by  cholecystotomy. 

Patient  made  a  good  recovery,  and  is  now  well. 

Treatment. — If  possible,  the  cause  should  be  removed  ;  but 
should  this  prove  impossible,  the  ducts  can  be  drained. 
Fortunately,  this  may  be  accomplished  with  every  prospect 
of  success  if,  as  is  commonly  the  case,  the  disease  be  gall- 
stones. Cases  56,  57,  92,  136,  153,  161,  and  162,  etc.,  are 
good  examples. 

There  can  be  no  doubt  in  the  minds  of  those  who  have 
observed  many  of  these  cases  that  it  is  better  to  anticipate 
the  complication,  and  as  soon  as  medical  treatment  has  been 
fairly  tried  and  failed,  the  removal  of  gall-stones  by  surgical 
means  should  be  resorted  to  before  infection  of  the  bile 
passages  has  occurred. 

SUPPURATIVE  CHOLANGITIS. 

Suppurative  Cholangitis,  or  Suppurative  Catarrh  of  the  Bile- 
ducts,  is  a  subject  of  deep  interest,  and  the  disease  of  serious 
import,  not  only  on  account  of  its  causes,  but  from  the  com- 
bined effects  of  biliary  obstruction  and  stagnation,  with 
septic  infection,  and  their  local  and  constitutional  effects. 

Etiology. — Cholelithiasis  is  by  far  the  most  common  cause, 
and  in  the  museums  there  are  several  cases  illustrating  it. 
Specimen  No.  1,418  in  Guy's  Museum  shows  dilated  hepatic 
ducts  containing  pus  and  many  dark-coloured  gall-stones, 
the  ducts  throughout  the  liver  being  inflamed  and  dilated, 
and  there  being  several  abscess  cavities ;  one  gall-stone  is 
free  in  the  common  duct.  The  specimen  was  taken  from  a 
woman,  aged  thirty,  who  had  had  enteric  fever  five  months 
before  death.  At  first  she  had  an  enlargement  of  the  gall- 
bladder, which,  however,  disappeared.  Death  occurred  from 
pyrexia,  accompanied  by  rigors. 

Case  236  affords  a  good  example  of  infective  cholangitis, 
dependent  on  gall-stones,  passing  on  to  suppurative  cholan- 
gitis,  in   which,   although  the   gall-stones   were   thoroughly 


INFLAMMATORY  AFFECTIONS  101 

removed  from  both  the  common  and  hepatic  ducts,  and  the 
pus  and  infected  bile  freely  evacuated,  the  patient,  who  had 
heart  disease  and  albuminuria,  was  too  far  reduced  by  her 
illness  to  withstand  the  operation,  which  offered  the  only 
chance  of  recovery. 

Case  12  is  interesting  as  being  a  well-marked  case,  in 
which  the  disease  was  dependent  on  gall-stones,  followed  by 
cancer  of  the  common  bile-duct.  Though  temporary  relief 
was  given  by  drainage,  the  patient  ultimately  succumbed  to 
the  disease,  and  at  the  autopsy  the  bile-ducts  throughout  the 
liver  were  found  full  of  pus. 

Case  287  is  one  of  gall-stone  in  the  common  duct  producing 
chronic  pancreatitis  and  suppurative  cholangitis,  in  which,  on 
account  of  the  extreme  illness  of  the  patient,  a  cholecyst- 
enterostomy  was  performed  as  being  a  more  rapid  operation 
than  choledochotomy  at  that  time,  whereas  now,  by  adopting 
the  method  of  liver  rotation,  I  should  have  performed  chole- 
dochotomy in  even  less  time  and  with  better  ultimate  results. 

A  man,  aged  forty-five  years,  from  Queensbury,  was  admitted 
to  the  Leeds  General  Infirmary  under  my  care  on  November  3, 
1899,  suffering  from  jaundice,  with  repeated  attacks  of  pain 
and  ague-like  seizures.  He  had  been  well  up  to  thirteen 
months  before  his  admission,  when  the  attacks  began,  and 
since  their  onset  he  had  lost  6  stone  in  weight.  Jaundice 
followed  the  first  seizure  and  persisted,  but  after  each  attack 
of  pain  it  was  more  intense.  He  was  so  weak  and  ill  that 
it  was  feared  he  could  not  bear  the  operation.  An  enlarge- 
ment of  the  right  lobe  of  the  liver  could  be  felt,  and  on  its 
inner  side,  in  the  mid-line  just  above  the  umbilicus,  there 
was  another  tumour  situated  behind  the  stomach.  On 
November  9  an  operation  was  performed  on  a  heated  table 
with  the  patient  enveloped  in  wool,  an  injection  of  10  minims 
of  solution  of  strychnia  having  been  previously  given.  On 
opening  the  abdomen,  an  enlargement  of  the  right  lobe  of  the 
liver  was  seen  ;  the  gall-bladder  was  found  shrunken  under 
adhesions,  a  floating  gall-stone  too  hard  to  crush  was  felt 
in  the  common  duct,  and  a  hard  nodular  tumour  of  the  head 
of  the  pancreas  was  discovered.  As  the  latter  was  thought 
to    be    malignant    and    the    patient    was  extremely   feeble, 


102    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

choledochotomy  was  not  performed,  but  the  gall-bladder  was 
connected  to  the  duodenum  by  a  Murphy's  button,  in  order 
to  give  temporary  relief  to  the  jaundice,  fever,  and  pain. 
He  had  a  severe  rigor  on  the  night  of  operation,  but  after- 
wards progressed  satisfactorily  and  recovered  from  the 
operation.  The  button  passed  on  the  twelfth  day,  and  as 
he  had  gained  some  weight  and  was  taking  his  food  well,  it 
was  thought  that  the  operation  was  going  to  be  of  real 
benefit  to  him.  The  subsequent  history  of  the  case  was  as 
follows  :  On  December  8  (a  month  and  a  day  after  opera- 
tion) he  had  a  feeling  of  chilliness,  and  a  temperature  of 
ioi°  F.  followed  for  two  days,  his  temperature  afterwards 
being  normal  for  twelve  days,  when  he  had  a  rigor  and  a 
return  of  the  jaundice  ;  from  this  time,  although  he  got  up 
every  day,  he  gradually  became  weaker,  and  in  January, 
1900,  he  developed  bronchitis,  which  ushered  in  the  final 
scene.  At  the  post-mortem  examination  the  peritoneum 
was  found  to  be  free  from  inflammation,  and  the  gall-bladder 
was  found  to  be  connected  to  the  duodenum  i|  inches 
bevond  the  pylorus,  but  the  opening  had  contracted  so  that 
it  would  only  admit  a  fine  probe.  The  common  bile-duct 
was  dilated  and  ulcerated,  and  it  contained  a  gall-stone  of 
the  size  of  a  filbert.  The  liver  was  considerably  enlarged, 
and  the  right  lobe  was  occupied  by  an  abscess  containing 
thick,  slimy  muco-pus.  The  walls  of  the  abscess  cavity  were 
ragged  and  ill-defined,  and  it  reached  nearly  to  the  surface 
both  in  front  and  behind.  It  was  doubtless  the  result  of 
the  suppurative  cholangitis  which  was  present.  The  head 
of  the  pancreas  was  much  indurated,  and  together  with  the 
indurated  tissues  in  the  small  omentum  presented  on  palpa- 
tion the  sensation  of  a  tumour.  On  section  it  presented  to 
the  naked  eye  the  appearance  of  chronic  inflammation  rather 
than  growth,  and  on  microscopical  examination  this  view 
was  confirmed,  there  being  a  great  excess  of  interstitial 
fibrous  tissue,  but  no  sign  of  cancer. 

Besides  gall-stones  ;  hydatid  disease,  ascarides,  cancer  of 
the  bile-ducts,  typhoid  fever,  and  influenza  may  cause  sup- 
purative cholangitis,  and  it  is  probable  that  the  disease  not 
infrequently  complicates  other  acute  infectious  ailments. 


PLATE  VII, 


Fig.  26. — Hydatid,  rolled  up  and  blocking  Common  Bile-duct, 
Portion  projecting  into  Duodenum. 

Taken  from  a  boy  of  fourteen,  who  had  a  large  hydatid  cyst  in  right 
lobe  of  liver.  Death  from  suppurative  cholangitis.  (No.  2,252, 
St.  Bartholomew's  Museum.) 


Fig  .  7. — Infective  Cholangitis,  showing  Dilated  Intra-hepatic  Ducts. 

Cause  :  cancer  of  ampulla  of  Vater      (No.  I.307A,  St.  Thomas's  Museum.) 
To  face  p.  102.] 


IN  FLA  MM  A  TOR  Y  A  FFECTIONS  103 

Hydatid  Disease  causing  infective  cholangitis  is  apparently 
not  rare,  as  the  specimens  in  many  of  the  museums  show. 

No.  2,252,  St.  Bartholomew's  Museum,  shows  a  hydatid 
membrane  rolled  up  and  blocking  the  common  bile-duct,  a 
portion  of  it  projecting  into  the  duodenum.  There  was  a 
large  hydatid  cyst  in  the  right  lobe  of  the  liver.  It  was 
taken  from  a  boy,  aged  fourteen,  who  died  from  jaundice, 
accompanied  by  pain,  fever,  and  delirium.  Three  months 
before  death  he  is  said  to  have  had  hepatitis  (Fig.  26). 

No.  1,384,  Guy's  Museum,  shows  a  hydatid  cyst  opening 
into  the  hepatic  duct,  a  piece  of  hydatid  membrane  project- 
ing through  the  papilla  into  the  duodenum.  The  ducts 
throughout  the  liver  are  dilated  and  filled  with  pus.  It 
occurred  in  a  man  of  fifty,  who  had  had  jaundice  a  month 
before  admission,  and  died  a  week  after. 

No.  196A,  St.  George's  Museum,  and  No.  1,582,  Middlesex 
Museum,  are  also  examples. 

Case  161  of  my  series  affords  an  example  of  successful 
operation  for  infective  cholangitis  dependent  on  hydatid 
disease,  and  Case  532  is  an  example  of  infective  cholangitis 
and  chronic  pancreatitis  dependent  on  hydatid  disease. 

Mr.  Jonathan  Hutchinson,  junior,  has  also  told  me  of 
another  case  in  which  he  operated  on  a  young  woman  suffer- 
ing from  intense  paroxysmal  pain,  with  high  temperature 
and  sickness,  in  whom  the  gall-bladder  could  be  felt  as  a 
very  tense  tumour.  Cholecystotomy  was  performed,  and 
numerous  hydatids  let  out.  An  opening  could  be  felt 
between  the  cyst  in  the  liver  and  the  gall-bladder.  Pus 
escaped  with  the  bile  for  a  time,  but  the  patient  is  now  well. 

Ascarides  in  the  Bile-ducts. — Mertens  has  collected*  forty- 
eight  cases  in  which  ascarides  have  been  found  in  the 
bile-ducts.  In  only  five  cases  were  there  symptoms  pointing 
to  the  presence  of  gall-stones,  and  in  two  only  was  the  cause 
of  the  symptoms  determined  during  life.  Mertens'  patient, 
a  woman,  aged  thirty,  was  admitted  into  hospital  after  her 
third  attack  of  biliary  colic,  which  simulated  closely  an 
ordinary  gall-stone  seizure,  beginning  with  pain  in  the  gall- 
bladder region,  associated  with   vomiting   and  followed  by 

*  Deutsche  Med.  Wochenschrift,  1898,  No.  23. 


104    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

jaundice.  On  admission,  both  the  liver  and  spleen  were  en- 
larged, and  the  gall-bladder  could  be  made  out,  though  it 
was  not  tender.  There  was  present  almost  complete  obstruc- 
tion to  the  flow  of  bile  into  the  intestine.  Pleurisy  with 
effusion  occurred  on  the  right  side,  and  was  followed  by  the 
development  of  ascites  and  oedema  of  the  legs.  The  patient 
rapidly  lost  strength  for  seven  weeks,  and  the  jaundice  be- 
came very  marked.  Then  two  partially  macerated  round 
worms  were  found  in  the  stools,  and  the  patient  rapidly 
began  to  improve,  ultimately  getting  quite  well. 

The  other  case,  the  cause  of  which  had  been  diagnosed 
during  life,  showed  the  ordinary  signs  and  symptoms  of  sup- 
purative cholangitis;  but,  in  addition,  round  worms  were 
vomited  and  also  found  in  the  motions.  The  child  ultimately 
died,  and  post-mortem  examination  revealed  dilated  bile- 
ducts,  with  multiple  abscesses  in  the  liver. 

Mertens'  supposition,  that  the  worms  were  enabled  to  enter 
the  common  duct  from  the  duodenum  by  reason  of  the  ducts 
having  been  dilated  by  the  previous  passage  of  gall-stones, 
seems  to  be  the  most  likely  explanation  of  their  presence  in 
such  an  unusual  situation. 

Ogilvie  (British  Medical  Journal,  January  12,  1901)  reports 
a  case  of  a  girl,  aged  sixteen,  who  developed  jaundice  during 
the  first  week  of  an  attack  of  typhoid  fever.  After  some 
days  a  round  worm,  a  third  of  which  was  stained  with  bile 
pigment,  was  passed  in  the  motions,  and  the  jaundice  rapidly 
disappeared,  complete  recovery  ensuing. 

Malignant  Disease  is  a  common  cause. 

There  is  an  excellent  example  (i,307a)  in  St.  Thomas's 
Hospital  Museum,  where  the  ducts  throughout  the  liver  are 
dilated  and  filled  with  pus,  the  infective  cholangitis  being 
dependent  on  malignant  disease  of  the  papilla  of  the  common 
bile-duct  (Fig.  27). 

Case  12  is  that  of  a  man,  aged  forty-two,  who  suffered 
from  deep  jaundice,  with  intermittent  fever  and  ague-like 
attacks.  Cholecystotomy  gave  relief,  but  the  patient  died  a 
few  weeks  after,  when  a  growth  of  a  malignant  character  was 
found  in  the  common  bile-duct,  and  the  ducts  throughout  the 
liver  were  inflamed  and  filled  with  pus. 


PLATE  VIII. 


is  itftute 


Fig.  28. — Inflammation  of  Gall-bladder  and  Bile-ducts  in  Typhoid. 
Death  in  seventh  week.      (No.  1,395,  Guy's  Museum.) 


To  face  p.  104.] 


INFLAMMATORY  AFFECTIONS  105 

Typhoid  Fever  furnishes  the  museums  with  several  specimens 
of  infective  and  suppurative  cholangitis. 

No.  1,395,  Guy's,  is  a  specimen  from  a  patient  of  Dr.  Hale 
White's,  which  shows  inflammation  of  the  bile  passages  and 
cholecystitis  without  any  obstruction  in  the  ducts.  Death 
occurred  in  the  seventh  week  (Fig.  28). 

No.  i,594A  in  the  Middlesex  Museum  shows  inflammation 
and  ulceration  of  the  bile  passages  in  typhoid  fever. 

Influenza  is  not  generally  recognised  as  a  cause  ;  but  cases 
have  occurred  in  which  the  symptoms  have  been  quite 
characteristic,  and  have  come  on  within  a  few  weeks  after 
an  attack.  I  have  myself  obtained  a  history  of  influenza 
as  the  apparent  cause  of  infective  cholangitis  on  several 
occasions. 

The  causes  mentioned  may  truly  be  termed  predisposing, 
since  the  true  exciting  cause  is  the  presence  of  pyogenic 
organisms. 

The  B.  coli  communis  produces  an  exudative  inflammation 
of  the  ducts,  and  may  actually  cause  abscesses  within  the 
walls  of  the  biliary  passages. 

Hepatitis  and  liver  abscess  frequently  follow  on  cholangitis, 
and  this  is  usually  followed  by  general  and  fatal  infection  of 
the  system. 

Endocarditis  is  at  times  set  up,  and  as  it  has  been  known* 
to  follow  cholangitis  without  hepatitis,  and  cholangitis  with- 
out abscess,  this  possible  cause  should  never  be  lost  sight  of 
in  any  case  of  ulcerative  endocarditis. 

The  bacillus  in  these  cases  in  the  vegetations  on  the  in- 
flamed endocardium  has  been  found  to  be  identical  with  the 
one  found  in  the  bile. 

Jaccoud  and  Aubertt  also  found  endocarditis  present  in 
cases  of  cholangitis. 

Symptoms. — In  suppurative  cholangitis  there  is  progressive 
enlargement  of  the  whole  liver,  which  may  descend  as  low 
as  the  umbilicus,  the  swelling  being  uniform,  smooth,  and 
tender  to  pressure ;  but  the  enlargement  ma)'  be  masked  by 
cirrhosis,  as  in  a  casej  reported  by  Drs.  Jones  and  Clinch. 

*  Netter  and  Martha,  Archives  de  Physiologic,  vol.  i\\,  1886. 

f  Clin.  Med.  de  Lariboisiere. 

+  Edi)iburgh  Med.  Joitrn.,  April,  1899. 


106    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

If  the  cause  be  in  the  common  duct,  and  the  gall-bladder 
has  not  previously  become  contracted,  there  will  be  the 
additional  enlargement  caused  by  its  distension  ;  but  when 
contraction  has  taken  place,  and  also  when  the  obstruction 
is  in  the  hepatic  duct,  there  will  be  an  absence  of  the  signs 
of  empyema  of  the  gall-bladder. 

Pain  may  be  entirely  absent  where  the  disease  is  associated 
with  cancer  of  the  common  duct ;  but  where  it  is  dependent 
on  gall-stones,  the  pain  may  be  severe  and  paroxysmal,  each 
attack  being  accompanied  by  ague-like  seizures  and  an 
intensification  of  the  jaundice. 

Jaundice  is  always  present,  and  is  usually  both  persistent 
and  intense,  though  where  the  obstruction  is  a  floating  gall- 
stone acting  like  a  ball-valve  in  the  common  duct,  the 
jaundice  may  vary  from  time  to  time,  and  may  almost  dis- 
appear between  the  attacks  of  pain.  Fever,  with  occasional 
rigors  and  profuse  perspiration,  forms  a  feature  of  the  disease, 
and  with  this  there  is  rapid  loss  of  flesh  and  strength. 

Pneumonia  and  pleurisy,  ending  in  empyema,  are  serious 
and  not  infrequent  complications  of  suppurative  cholangitis. 
The  disease  is  an  extremely  serious  one,  and  usually  proves 
fatal,  though,  if  the  cause  can  be  removed  at  an  early  stage, 
recovery  may  occur. 

If  the  course  be  less  acute,  the  inflammation  may  con- 
centrate itself  in  some  part  of  the  liver,  leading  to  abscess, 
which  may  form  a  distinct  tender  swelling,  and  give  rise  to 
the  usual  symptoms  and  signs  of  hepatic  abscess. 

Treatment. —  Unless  free  evacuation  and  drainage  of  the 
infected  contents  of  the  bile  passages  can  be  accomplished, 
cither  naturally  or  artificially,  treatment  is  practically  use- 
less. Therefore,  if  practicable,  cholecystotomy  should  be 
performed,  and  free  drainage  established  and  continued  until 
the  bile  is  sterile,  or  nearly  so. 

Although  good  results  cannot  be  expected  in  all  cases,  an 
amelioration  of  the  symptoms  may  be  looked  for  in  a  fair 
proportion,  and  complete  relief  in  others. 

If  a  localized  abscess  be  discovered  in  the  liver,  it  should 
be  opened  and  drained,  and  though  it  is  scarcely  to  be  ex- 
pected that  operation  can  be  always  successful  in  these  more 


INFLAMMATORY  AFFECTIONS  107 

serious    cases,    the    chance    of   permanent    benefit  is    worth 
snatching  at,  even  in  the  most  desperate  conditions. 

Of  general  means,  warm  applications  to  the  hepatic 
regions,  an  initial  mercury  purge  followed  by  milder  laxatives, 
the  employment  of  intestinal  antiseptics,  such  as  bismuth 
and  salol,  the  relief  of  pain  by  sedatives  (if  called  for),  and  the 
treatment  of  symptoms  as  they  arise,  will  afford  some  ameliora- 
tion, though  they  will  probably  only  give  temporary    relief. 

Surgeons  have  been  performing  cholecystotomy  for  infective 
and  suppurative  cholecystitis  and  for  gall-stones  producing 
these  diseases  for  some  years,  Cases  3,  6,  and  12,  operated  on 
by  me  in  1888,  being  among  the  earliest  examples  of  this 
operation. 

Cholecystotomy  and  drainage  of  the  bile-ducts  is  the 
operation  called  for,  and  at  the  same  time  the  obstruction, 
if  one  be  present,  should  if  possible  be  removed  ;  though  in 
some  cases,  where  the  patient  is  extremely  ill,  the  latter  part 
of  the  operation  may  be  deferred  until  the  drainage  has 
cleared  away  all  the  infective  material. 

Thanks  to  the  opening  in  the  gall-bladder,  a  certain 
number  of  important  therapeutic  results  follow  : 

First.  The  septic  contents  of  the  gall  -  bladder  are 
evacuated. 

Second.  Calculi,  which  are  most  frequently  present  there, 
are  removed. 

Third.  The  other  biliary  passages,  more  or  less  obstructed 
either  by  calculi  or  by  swelling  of  their  walls,  are  rendered 
as  free  as  possible. 

Fourth.  The  septic  bile  is  allowed  to  escape,  and  mechani- 
cally washes  out  the  lower  passages,  carrying  away  through 
the  drainage-tube  many  of  the  infective  elements. 

Fifth.  The  relief  of  pressure  prevents  absorption  of  the 
septic  matter. 

Sixth.  The  relief  to  the  kidneys,  by  allowing  the  bile  to 
escape  freely,  is  also  of  importance,  as  they  are  thus  enabled 
to  perform  their  function  more  freely  in  relieving  the  system 
of  septic  and  other  materials. 

Seventh.  The  swelling  of  the  head  of  the  pancreas, 
'  chronic  pancreatitis,'  so  often  present  where  the  common 


108    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

bile-duct  is  obstructed,  subsides  owing  to  the  indirect  drain- 
age of  the  pancreatic  ducts. 

M.  Terrier  {Revue  de  Chiritrgie,  1895,  p.  966)  relates  several 
cases  with  the  utmost  detail,  especially  interesting  on  account 
of  the  bacteriological  examination  of  the  discharge  from  the 
fistula  at  different  dates,  conclusively  showing  the  gradual 
diminution  in  the  virulency  of  the  bile  after  the  drainage 
has  been  proceeding  for  some  days,  and  pointing  to  the  need 
of  rather  more  prolonged  drainage  than  some  of  us  have 
been  wont  to  employ — i.e.,  until  a  bacteriological  examination 
of  the  discharge  shows  it  to  be  sterile,  or  nearly  so. 

Tubercular  Cholangitis  seems  to  occur  as  a  rare  condition, 
and  apparently  only  as  a  sequel  to  tubercular  infection  of  the 
intestine.  Tubercles  seem  to  form  in  the  portal  canals,  and 
by  extension  to  involve  the  bile-ducts  and  give  rise  to  well- 
marked  cholangitis.  It  is  possible  that  in  some  cases  of 
extensive  tuberculosis  of  the  intestine  the  infection  may  be 
direct,  but  the  cases  have  mostly  occurred  in  patients  the 
subject  of  general  tuberculosis,  and  in  all  probability  the 
bacilli  are  carried  by  the  blood-stream.  As  the  lymphatic 
stream  in  the  liver  is  toward  the  hilum,  it  is  not  likely  that 
infection  is  brought  in  that  way.  This  form  of  cholangitis  is 
practically  of  little  importance,  as  it  forms  merely  a  compli- 
cation in  what  is  necessarily  a  fatal  condition. 


ULCERATION  OF  THE  GALL-BLADDER  AND  BILE-DTJCTS. 

Ulcers  of  the  gall-bladder  or  bile-ducts  vary  greatly  in 
number,  size,  and  depth,  as  also  in  clinical  importance. 

They  may  be  quite  superficial,  being  mere  abrasions  of  the 
epithelial  lining  of  the  mucous  membrane,  then  being  as  a 
rule  numerous  and  widespread,  or  they  may  be  single  and 
deep,  extending  into  or  through  the  muscular  and  serous 
coats.  Between  these  extremes  every  variety  may  be  found, 
as  the  specimens  in  the  museums  show  very  distinctly. 

Although  cholelithiasis  is  the  most  frequent,  typhoid  fever 
and  cancer  are  quite  common  causes,  and  cholera  is  also  said 
to  produce  ulcers. 

The  slighter  cases   of  erosion    are   seldom   seen,    though 


PLATE  IX. 


Liver  held  up 
by  retractors 


Gall-bladder 


Stomach 


Fig.  29 — Adhesion  of  Gall-bladder  to  Stomach,  leading  to  Dilatation 
of  Stomach  and  Spasmodic  Pain. 


To  /ace  p.  108.] 


INFLAMMATORY  AFFECTIONS  109 

doubtless  they  frequently  exist  in  cases  operated  on  for  gall- 
stones, and  in  others  where  the  concretions  are  passed 
naturally ;  but  the  severer  forms  of  ulceration  are  more  fre- 
quently met  with  as  the  immediate  cause  of  death. 

Ulceration  is  chiefly  of  importance  on  account  of  the 
serious  sequelae — stricture,  perforation,  fistula,  peritonitis 
(local  or  general),  haemorrhage,  septicaemia  and  pyaemia. 

The  inflammation  accompanying  ulceration  usually  ex- 
tends to  the  peritoneal  coat  at  the  site  of  the  ulcer,  and  leads 
to  a  plastic  peritonitis,  which  causes  the  adjoining  organs  to 
adhere  to  the  inflamed  surface,  thus  in  the  greater  number  of 
cases  keeping  the  peritonitis  local. 

Adhesions. — Some  years  ago*  we  pointed  out  that  in  nearly 
every  case  of  gall-stones  there  are  adhesions  of  the  gall- 
bladder or  ducts  to  neighbouring  organs,  showing  that 
peritonitis  is  a  frequent  or  nearly  constant  accompaniment 
of  cholelithiasis.  It  is  doubtless  a  salutary  phenomenon, 
as  otherwise  general  peritonitis  would  be  much  more  common, 
especially  in  the  many  cases  where  the  adhesions  permit  of 
fistulae  quietly  forming  between  the  contiguous  viscera,  and 
where  localized  abscesses  form  without  general  peritonitis. 

The  adhesions  may,  either  by  the  anchoring  of  normally 
mobile  organs  or  by  subsequent  contraction,  themselves 
become  sources  of  inconvenience  or  danger,  as  in  the  case  of 
a  lady  of  thirty-four  (Case  97),  who,  besides  suffering  from 
severe  spasmodic  pain  due  to  chronic  catarrhal  cholecystitis, 
had  dilatation  of  the  stomach  owing  to  kinking  of  the  pylorus, 
caused  by  adhesions  passing  between  it  and  the  gall-bladder. 
(See  Fig  29.)  After  separation  of  the  adhesions  and  drainage 
of  the  gall-bladder,  complete  recovery  ensued. 

Mr.  Page,  of  Newcastle,  recently  described  a  similar  caset 
in  which  an  acute  kink  of  the  pylorus  led  to  dilatation  of  the 
stomach,  with  vomiting  and  death.  The  gall-bladder,  con- 
taining gall-stones,  was  adherent  to  the  pylorus,  and  com- 
municated with  it  through  an  ulcerated  opening. 

Case  219  is  a  good  example  of  ulceration  of  the  gall- 
bladder followed  by  adhesion  to  the  stomach,  and  ending  in 

*  Clin.  Soc.  Transactions,  j888. 

f  British  Medical  Journal,  January  23,  1897. 


no    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

a  fistula  between  the  gall-bladder  and  stomach.  Persistent 
vomiting  of  bile,  with  repeated  attacks  of  pain  and  great  loss 
of  flesh,  resulted.  At  the  operation,  the  gall-bladder  was  de- 
tached from  the  stomach,  and  the  opening  into  the  stomach 
sutured.  A  number  of  gall-stones  were  removed  from  the 
gall-bladder  through  the  fistulous  opening,  which  was  brought 
to  the  surface,  and  used  for  the  purpose  of  draining  the 
bladder  and  ducts.  The  patient  made  a  good  recovery,  and 
is  now  well. 

In  other  cases  (Nos.  54,  63,  87,  and  130)  the  fibrous  trans- 
formation of  the  lymph  led  to  contraction  with  stricture  of 
the  pylorus,  which  was  relieved  by  separating  the  adhesions ; 
but  in  another  case  (No.  131)  the  strictured  pylorus  was  so 
narrow  that  pyloroplasty  had  to  be  performed,  which  effected 
a  complete  cure. 

In  another  instance  (No.  160),  the  adhesions  between  the 
gall-bladder  and  colon  led  to  partial  obstruction  of  the 
bowels,  with  frequent  recurrences  of  colic,  all  relieved  by 
separating  the  fibrous  bands. 

Case  199  is  a  good  example  of  typhoidal  cholecystitis  being 
followed  by  adhesion  of  the  gall-bladder  to  the  hepatic  flexure 
of  the  colon.  The  adhesions  ultimately  formed  strong  bands 
encircling  the  colon  and  causing  obstruction,  which  was 
cured  by  their  division. 

On  looking  through  the  list  of  cases,  it  will  be  found  that 
in  many  instances  adhesions  were  found  to  account  for  the 
symptoms,  and  that  their  separation  usually  afforded  relief  or 
cured  the  patients. 

Peritonitis,  though  usually  local  in  cases  of  cholelithiasis, 
may  become  general,  either  from  perforation,  as  in  cases  to 
be  related  under  that  heading,  or  by  extension  to  the  peri- 
toneum, through  the  non-perforated  walls,  as  in  cases 
related  under  the  description  of  phlegmonous  or  gangrenous 
cholecystitis. 

Under  such  circumstances  prompt  surgical  treatment  will 
be  required,  or  death  will  speedily  follow. 

It  is  important  to  note  that  in  perforative  peritonitis  from 
diseases  of  the  gall-bladder  or  bile-ducts  the  effusion  is  at 
first  limited   to  the  larger   pouch  on  the   right   side  of  the 


INFLAMMATORY  AFFECTIONS  nr 

abdomen;  these  cases  are  therefore  very  amenable  to  treat- 
ment if  operated  on  within  a  short  time  of  the  catastrophe, 
whereas  in  case  of  delay  the  fluid,  which  is  infective,  tends 
to  pass  into  the  pelvis  and  to  produce  general  infection  of  the 
peritoneum. 

Haemorrhage. — As  the  ulcer  extends,  the  vessels  usually 
become  thrombosed,  but  occasionally  severe  haemorrhage 
results,  leading  either  to  haematemesis  or  melaena. 

The  notes  of  the  following  fatal  case  were  given  me  by 
Dr.  Peter  McGregor  of  Huddersfield. 

A  temperate  man  of  forty-eight  had  suffered  from  gall- 
stone attacks  since  the  age  of  twenty-six,  but  for  a  year  had 
had  no  seizure,  and  had  gained  2  stones  in  weight. 

Without  pain  or  other  localizing  sign,  he  began  to  vomit 
blood,  and  continued  to  do  so  two  or  three  times  a  day 
until  his  death,  which  resulted  from  exhaustion  in  the 
third  week. 

An  autopsy  revealed  contraction  of  the  liver,  with 
numerous  gall-stones  in  the  gall-bladder.  One,  the  size 
of  a  large  filbert,  had  ulcerated  through  the  walls  of  the 
gall-bladder,  and  was  projecting  into  the  peritoneal  cavity. 
There  was  no  peritonitis,  and  death  was  due  to  haemorrhage 
from  the  margin  of  the  ulcerated  opening. 

Specimen  No.  1,389,  Guy's  Museum,  shows  the  gall-bladder 
and  bile-ducts  of  a  woman  of  fifty-four,  who,  after  being- 
jaundiced  for  two  months,  suddenly  became  collapsed,  with 
a  rapidly-increasing  swelling  of  the  gall-bladder.  This  was 
opened  by  Mr.  Lane  on  the  fifth  day,  and  was  found  to  be 
filled  with  blood-clot.  She  died  a  few  hours  after,  when  the 
bleeding  was  found  to  have  proceeded  from  a  laceration  in  a 
softened  and  ulcerated  gall-bladder.* 

It  is  to  be  borne  in  mind  that  haemorrhage  is  predisposed 
to  in  these  cases  by  the  aplastic  condition  of  blood  occurring 
in  long-standing  jaundice. 

As  ulceration  is  always  associated  with  the  presence  of 
pyogenic  organisms,  septic  absorption  usually  occurs,  leading 
to  constitutional  disturbances  in  the  shape  of  septicaemia  and 
pyaemia,  as  described  under  infective  cholangitis. 

*  Clin.  Soc.  Transactions,  1895,  p.  160. 


ii2    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Cancer. — Although  cancer  may  lead  to  ulceration,  it  seems 
probable  that  long-standing  ulceration  of  the  gall-bladder  or 
bile-ducts  may  predispose  to  malignant  disease,  as  they  are 
so  frequently  associated.  This  subject  is  more  fully  discussed 
under  the  heading  of  Tumours. 

A  specimen  illustrative  of  ulceration  (No.  2,263,  St.  Bar- 
tholomew's Museum)  shows  a  circular  ulcer  in  the  gall- 
bladder, dependent  on  gall-stones. 

No.  2,263A,  St.  Bartholomew's  Museum,  shows  many 
small  ulcers,  with  a  larger  one  that  has  perforated  and  caused 
death  from  peritonitis.  The  walls  of  the  gall-bladder  are 
greatly  thickened,  and  there  is  a  cholesterine  coating,  but 
there  are  no  gall-stones.  The  patient  was  a  man  of  sixty- 
seven. 

No.  1,675,  King's  College  Museum,  shows  numerous  ulcers 
due  to  gall-stones. 

No.  i,594A,  Middlesex  Museum,  affords  a  beautiful  example 
of  deep  ulcers  due  to  typhoid  fever  (Fig.  30). 

No.  1,021,  St.  Mary's  Museum,  shows  an  epithelioma  of 
the  gall-bladder,  with  a  perforating  ulcer,  occurring  in  an  old 
lady,  and  leading  to  death  from  peritonitis  (Fig.  31) ;  and 
No.  2,8oqa,  from  the  Hunterian  Museum,  shows  the  ulcera- 
tion of  a  malignant  stricture,  causing  a  fistula  between  the 
gall-bladder  and  colon  (Fig.  32). 

STRICTURE  OF  THE  GALL-BLADDER  AND  BILE-DUCTS. 

Stricture  of  the  bile-ducts  is,  I  should  judge  by  my  experi- 
ence on  the  operating-table,  very  common,  especially  stricture 
of  the  cystic  duct ;  yet  if  we  might  judge  by  museum  speci- 
mens alone,  it  would  seem  to  be  one  of  the  rarer  sequelae  of 
ulceration,  by  which  it  is  probably  always  preceded,  except 
in  those  cases  dependent  on  malignant  disease,  which  arc 
considered  under  another  heading. 

Though  there  is  no  reason  why  stricture  should  not  be  a 
sequence  of  typhoid  ulceration,  such  has  yet  to  be  proved,  and 
the  only  cases  concerning  which  we  can  glean  information 
have  followed  on  cholelithiasis,  or  new  growth. 

Stricture  may  only  render  itself  evident  after  the  original 


PLATE  X. 


Fig.  30. — Typhoid  Ulceration  of  Gall-bladder. 
(No.  i,594A,  Middlesex  Museum.) 


Fig.  31. — Perforating  Epitheliomatous  Ulcer  of  Gall-bladder. 

(No.  1,021,  St.  Mary's  Museum.) 
To  face  p.  112.] 


IN  FLA  MM  A  TOR  Y  A  FFECTIONS  1 1 3 

cause  has  passed  away,  as  in  several  cases  of  stricture  of  the 
cystic  and  of  the  common  duct  on  which  I  have  operated, 
where  the  cause  in  the  shape  of  gall-stones  was  removed, 
and  the  strictures  which  developed  had  subsequently  to  be 
treated ;  and  in  another  case  of  stricture  of  the  common 
duct,  where  the  history  of  gall  -  stones  was  indubitable, 
though  none  were  found  when  the  abdomen  was  explored. 
(Cases  13,  22,  195,  etc.) 

Notwithstanding  the  probable  frequency  of  its  occurrence, 
a  search  through  the  museums  revealed  only  a  single  speci- 
men illustrating  simple  stricture  of  the  bile-ducts  :  that  is  in 
the  Hunterian  Museum  (No.  2,804),  an<^  shows  a  long 
stricture  of  the  common  duct ;  but  there  are  many  specimens 
showing  stricture  the  result  of  new  growth,  and  some  repre- 
senting obliteration  of  the  whole  duct  (Fig.  33). 

If  the  stricture  be  in  the  hepatic  duct,  it  will  lead  to  jaundice 
without  distension  of  the  gall-bladder ;  if  in  the  cystic  duct, 
to  distension  of  the  gall-bladder  without  jaundice;  but  if 
in  the  common  duct,  both  to  jaundice  and  distended  gall- 
bladder, unless  the  latter  be  contracted  as  the  result  of 
previous  gall-stone  trouble. 

Armeus  (These  de  Paris,  1896)  has  shown  that  it  is  possible 
for  the  contents  of  the  gall-bladder  to  remain  aseptic  in 
cases  of  obliteration  of  the  cystic  duct,  and  that  in  this 
condition  atrophy  of  the  organ  results. 

In  the  majority  of  the  cases,  however,  where  the  stricture 
of  the  cystic  duct  is  due  to  ulceration  following  the  impaction 
of  gall-stones,  extensive  changes  will  have  already  taken 
place  in  the  gall-bladder.  It  may  be  contracted,  the  walls 
being  composed  merely  of  cicatricial  tissue.  In  such. a  case 
the  contracted  gall-bladder  remains  quiescent. 

Where  extensive  changes  have  not  already  taken  place  in 
the  wall  of  the  gall-bladder,  and  where  the  mucous  mem- 
brane is  still  active,  distension  of  the  organ  with  mucus  or 
muco-pus  will  occur.  If  relief  is  not  afforded  by  operative 
measures,  of  which  cholecystectomy  is  chiefly  indicated, 
suppurative  or  phlegmonous  cholecystitis  may  occur,  or  the 
distended  organ  may  rupture  into  the  peritoneum,  or  dis- 
charge  its  contents   by  the   formation   of  a  fistula  between 

S 


U4    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

the  gall-bladder  and  duodenum,  stomach  or  colon  ;  or  the 
gall-bladder  may  gradually  dilate  so  as  to  form  a  tumour 
resembling  an  ovarian  cyst. 

The  following  case,  among  other  complications,  had  stric- 
ture of  the  cystic  duct,  necessitating  cholecystectomy  : 

Case  483. — Mr.  I.,  aged  fifty,  seen  with  Dr.  Brown,  of 
Taunton,  gave  the  history  that  he  had  been  subject  to  painful 
attacks,  called  indigestion,  from  the  age  of  fourteen  to  six- 
teen, but  that  he  had  been  free  from  the  seizures  until  sixteen 
years  ago,  when  acute  pain  was  felt,  followed  by  jaundice 
associated  with  fever  and  rigors.  Since  that  time  he  had 
had  similar  attacks  at  varying  intervals,  but  lately  there  had 
been  five  or  six  severe  seizures  in  rapid  succession,  accom- 
panied by  rigors,  continued  fever,  and  increase  of  jaundice. 
When  seen  by  me  the  liver  was  ih  inches  below  the  costal 
margin,  but  no  tenderness  could  be  detected  anywhere.  A 
slight  icteric  tinge  was  present  in  the  conjunctivae.  The 
attacks  appeared  to  have  been  brought  on  by  gastro-duo- 
denal  catarrh  extending  to  the  common  bile-duct  and  to  the 
pancreas.  A  diagnosis  of  gall-stones  in  the  common  duct 
was  made  and  an  operation  advised. 

Operation,  January  29,  1903. — The  gall-bladder  was  firmly 
adherent  to  the  surrounding  structures,  and  was  separated 
with  difficulty.  A  fistula  between  the  gall-bladder  and  the 
duodenum  was  thus  exposed,  and  after  separating  the  gall- 
bladder, the  opening  in  the  duodenum  was  closed  by  a  purse- 
string  suture.  Two  stones  were  felt  in  the  common  duct, 
and  there  was  also  some  swelling  of  the  head  of  the  pan- 
creas. The  stones  in  the  duct  were  crushed,  and  then 
extracted  by  the  scoop  after  incising  the  duct.  No  more 
stones  could  be  detected  in  the  ducts,  and  a  probe  readily 
passed  down  into  the  duodenum.  The  gall-bladder  was 
small  and  contracted,  and  the  cystic  duct  was  strictured  at 
the  junction  with  the  common  duct. 

Cholecystectomy  was  performed,  and  the  hepatic  duct 
was  drained  by  a  tube  passed  through  the  incision  in  the 
duct,  which  was  closed  around  it  by  a  catgut  suture.  A 
gauze  drain  was  passed  down  by  the  side  of  the  tube  and 
the  wound  closed. 


IN  FLA  MM  A  TOR  Y  A  FFECTIONS  1 1 5 

The  patient  made  a  good  recovery,  and  is  now  well. 

The  following  case  is  a  good  example  of  stricture  in  the 
common  duct  following  the  passage  of  gall-stones  some 
years  previously : 

Case  436. — Mrs.  T.,  aged  fifty,  seen  with  Dr.  Lawrence, 
of  Darlington,  April  26,  1902.  During  many  years  had 
frequent  attacks  of  biliary  colic,  but  she  had  been  quite 
free  from  them  for  five  years.  Twelve  months  ago  began 
to  have  shivering  attacks  with  epigastric  pain,  followed  by 
jaundice ;  lately  had  rigors  three  or  four  times  a  week. 
Three  months  ago  cholecystotomy  was  performed  in  New- 
castle, but  no  stones  discovered. 

When  seen  by  me  there  was  a  biliary  fistula  acting  incom- 
pletely, and  the  patient  was  suffering  from  infective  cholan- 
gitis, with  rigors,  fever,  and  slight  jaundice. 

Operation,  May  6,  1902. — The  pancreas  was  found  enlarged 
(chronic  pancreatitis),  and  a  gall-stone  was  removed  from 
the  common  duct  by  choledochotomy ;  but,  as  a  probe  would 
not  pass  into  the  duodenum,  the  bowel  was  opened  and  the 
papilla  found  strictured.  The  papilla  was  laid  open,  and  the 
duct  stretched  by  means  of  forceps. 

Recovery  from  operation  was  uninterrupted,  but  the  fistula 
never  completely  closed,  so  that  in  all  probability  the  stric- 
ture of  the  common  duct  recurred.  Cholecystenterostomy 
could  not  be  performed  on  account  of  the  contracted  state  of 
the  gall-bladder. 

Symptoms. — If  in  the  cystic  duct,  stricture  leads  to  a 
gradual  enlargement  of  the  gall-bladder,  which  may  be 
quite  painless,  as  in  Case  1 ;  almost  painless,  as  in  Case  2  ;  or 
which  may  give  rise  to  considerable  distress,  as  in  Case  10. 

If  in  the  common  duct,  jaundice  supervenes,  at  first  being 
only  slight,  but  ultimately  becoming  severe,  and  being  asso- 
ciated with  all  the  usual  distressing  and  dangerous  symptoms 
of  chronic  icterus,  as  shown  in  Cases  3  and  143.  The  liver 
enlarges,  and  may  descend  to  the  level  of  the  umbilicus  ;  the 
gall-bladder  may  also  enlarge,  though,  if  gall-stones  have 
been  the  cause,  the  gall-bladder  may  have  become  contracted 
and  so  be  incapable  of  distension. 

Stricture  of  the  hepatic  duct  is  probably  extremely  rare, 

8—2 


n6    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

for  we  can  only  find  an  account  of  one  case,  and  that  by 
Dr.  Wyeth,  who  related  the  history,  and  showed  the 
specimen  from  a  case  of  recurrent  gall-stone  obstruction,  in 
which  the  gall-bladder  was  found  collapsed  and  empty  at 
operation,  and  the  patient  died  unrelieved. 

A  post-mortem  examination  revealed  a  small  concretion  in 
the  peritoneal  cavity,  and  a  stricture  of  the  hepatic  duct 
where  the  gall-stone  had  ulcerated  its  way  through. 

A  form  of  stricture,  not  common,  may  be  found  in  the 
gall-bladder,  converting  that  ordinarily  pear-shaped  cavity 
into  the  form  of  an  hour-glass. 

Among  the  cases  abstracted  below  were  two  in  which  this 
condition  was  present.  In  one,  the  upper  cavity  was  separated 
from  the  lower  by  an  apparently  impermeable  stricture, 
though  both  cavities  contained  gall-stones.  The  upper  sac 
was  amputated  and  the  lower  drained,  after  the  concretions 
had  been  removed. 

A  specimen  in  the  Middlesex  Museum  shows  the  condition 
very  well. 

Needless  to  say,  stricture  of  the  bile  passages  will  scarcely 
call  for  diagnosis  apart  from  its  cause,  though  different  treat- 
ment will  be  demanded  when  the  disease  is  recognised  at  the 
time  of  operation.  In  stricture  of  the  cystic  duct  the  gall- 
bladder should  be  removed,  as  in  Cases  2,  22,  65,  and  257, 
etc.  ;  otherwise  a  recurrence  of  the  symptoms  will  occur 
when  the  wound  closes,  or  there  will  be  a  permanent  mucous 
fistula,  as  in  Case  1. 

The  following  are  examples  of  cholecystectomy  : 

Case  495. — Cholecystitis — Residual  Abscess— Chronic  Pan- 
creatitis— Cholecystectomy — Recovery. — Mr.  0.,aged  fifty-nine, 
seen  with  Dr.  Le  Rosignol,  Jersey.  A  year  ago  had  an 
attack  of  biliary  colic,  followed  by  numerous  other  attacks, 
the  last  two  having  been  accompanied  by  jaundice.  The 
liver  was  somewhat  enlarged,  and  there  was  tenderness  to 
the  right  of  and  above  the  umbilicus.  No  enlargement  of 
the  gall-bladder. 

Operation,  March  26,  1903. — Extensive  adhesions  ;  swelling 
<  »f  head  of  pancreas ;  remnant  of  abscess  between  the  gall- 
bladder  and   duodenum    found,    but    no    gall-stones;    gall- 


INFLAMMATORY  AFFECTIONS  1 17 

bladder  thickened  and  contracted ;  cystic  duct  strictured 
close  to  gall-bladder  ;  cholecystectomy ;  drainage  of  lower 
part  of  cystic  duct. 

After  History. — Patient  made  a  good  recovery,  and  was 
able  to  return  home  in  the  fifth  week. 

Case  434. — Gall-stones — Cholecystitis — Structure  of  Cystic 
Duct — Cholecystotomy. — Mrs.  J.,  aged  forty-one,  seen  with 
Dr.  Riley,  of  Sale.  For  five  years  had  suffered  from  attacks 
of  biliary  colic  without  jaundice.  Three  weeks  before  opera- 
tion had  a  very  severe  attack,  with  enlargement  of  the  gall- 
bladder and  local  peritonitis. 

Operation,  April  18,  1902. — The  gall-bladder  was  dilated 
with  pus,  and  was  thickened  and  inflamed.  The  pus  was 
removed  by  aspiration,  several  stones  were  extracted  from  the 
gall-bladder,  and  another  stone  discovered  impacted  in  the 
cystic  duct.  This,  which  could  not  be  pushed  upwards  into 
the  gall-bladder,  was  removed  by  incising  the  duct.  The 
cystic  duct  was  ulcerated  and  stenosed.  Cholecystectomy 
was  performed.  As  it  was  thought  that  a  stone  had  been 
felt  in  the  common  duct,  an  incision  was  made  into  the  duct 
for  exploration,  but  with  a  negative  result.  The  patient 
made  a  complete  recovery,  and  is  now  well. 

As  an  alternative,  the  gall-bladder  may  be  short-circuited 
into  the  intestine,  as  in  the  case  reported  by  Mr.  Paul  in  the 
Lancet  for  March  24,  1895  ;  but,  seeing  that  the  opening  in  a 
cholecystenterostomy  tends  to  close,  the  operation  of  chole- 
cystectomy is  preferable. 

In  stricture  of  the  common  duct,  cholecystenterostomy 
must  be  performed,  as  in  Case  13,  reported  below,  otherwise 
a  permanent  biliary  fistula  will  certainly  follow.  At  times, 
however,  this  may  be  impracticable,  and  in  such  cases 
drainage  alone  may  be  feasible. 

Case  13. — Cholecystotomy — Biliary  Fistula  apparently  due  to 
Stricture  of  the  Common  Duct — Cholecystenterostomy — Recovery. 
— On  January  9,  1888,  a  married  woman,  aged  forty-two, 
was  admitted  to  the  Leeds  General  Infirmary,  suffering  from 
acute  local  peritonitis,  with  a  tumour  in  the  region  of  the 
gall-bladder. 

On  January   14   laparotomy  was  performed  through    the 


n8    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

upper  part  of  the  right  linea  semilunaris,  and  8  ounces  of 
fetid  pus  removed  from  the  gall-bladder.  Exploration  of  the 
ducts  by  the  finger  and  a  probe  failed  to  discover  any  gall- 
stones. The  gall-bladder  was  stitched  to  the  abdominal 
wound  and  drained,  and  the  patient  made  a  good  recovery, 
but  with  a  biliary  fistula.  Although  she  had  retained  good 
health  during  the  fifteen  months  when  the  fistula  was  open 
and  discharging  the  whole  of  the  bile,  her  condition  was  a 
very  miserable  one,  since  no  apparatus  could  be  made  to 
catch  the  overflowing  fluid  when  she  was  walking  about,  and 
her  dressings  and  clothes  became  saturated. 

Cholecystenterostomy  was  performed  on  March  2,  1889, 
by  re-opening  the  abdomen  through  the  old  cicatrix  in  the 
right  semilunaris.  The  viscera  in  the  neighbourhood  were 
found  to  be  so  matted  together  that  it  seemed  to  be  im- 
possible to  fix  the  gall-bladder  to  the  duodenum,  and  as  the 
hepatic  flexure  of  the  colon  was  conveniently  near,  the  gall- 
bladder was  fixed  to  it  by  a  double  row  of  sutures  round  a 
decalcified  bone  bobbin,  a  free  communication  being  made 
between  the  two  viscera.  After  a  tardy  convalescence,  she 
completely  recovered,  and  was  well  in  every  respect  ten  years 
later. 

PERFORATION  OF  THE  GALL-BLADDER  AND  BILE-DUCTS. 

Perforation  of  the  gall-bladder  or  bile-ducts  must  always 
be  serious  on  account  of  an  escape  of  the  visceral  contents 
into  the  peritoneal  cavity;  the  imminence  of  the  danger, 
however,  depending  on  two  factors :  first,  the  nature  of  the 
extravasated  fluid ;  and,  secondly,  the  time  allowed  to  elapse 
before  surgical  relief  is  afforded. 

The  presence  of  healthy  bile  in  the  peritoneum,  due  to  an 
injury  such  as  a  stab,  a  bullet  wound,  or  a  blow,  in  a  healthy 
individual,  may  be  tolerated  for  some  time  without  serious 
damage,  as  in  a  case  recorded  by  Thiersch,  who  successfully 
removed  over  40  pints  of  bile-stained  fluid  from  the  abdominal 
cavity  after  the  gall-bladder  had  been  ruptured  by  a  blow. 

The  experiments  of  Schuppel  and  Bostrom  apparently 
prove  that  the  peritoneum  can  absorb  bile  without  serious 
trouble,  and  there  have  been  several  cases  reported  in  which 


IN  FLA  MM  A  TOR  Y  A  FFECTIONS  1 1 9 

cxtravasated  bile  has  been  successfully  evacuated,  either  by 
tapping  or  by  incision  and  drainage. 

In  the  chapter  on  injuries  of  the  bile  passages  it  is  shown 
that  healthy  bile  does  not  as  a  rule  give  rise  to  peritonitis, 
and  that  in  many  cases  extravasations  of  bile  into  the  peri- 
toneum after  injuries  to  the  bile  passages  have  been  absorbed. 
Such  a  fortunate  result  cannot,  however,  always  be  looked 
for,  as  is  shown  by  the  specimens  in  some  of  the  museums. 

It  is  of  far  more  serious  moment  when  the  extravasated  bile 
is  pathological,  as  it  for  the  most  part  is  where  there  is  disten- 
sion of  the  gall-bladder  or  any  disease  of  the  bile-ducts  ;  for  in 
such  cases  the  bile  is  infective,  and  rapidly  sets  up  a  diffuse 
peritonitis,  which,  unless  speedily  operated  on,  ends  fatally. 

Even  in  such  cases,  if  the  diagnosis  be  made  at  once  and 
early  operation  done,  the  prognosis  is  good,  as  in  the  case  of 
a  commercial  traveller,  aged  forty-five,  who  had  suffered  from 
gall-stone  seizures  for  twenty-nine  years,  and  whom  I  saw 
with  Dr.  Braithwaite,  of  Leeds  (No.  81). 

After  symptoms  of  inflammation  in  the  hepatic  region 
extending  over  several  weeks,  he  suddenly  became  worse 
and  showed  signs  of  general  peritonitis.  The  abdomen  was 
opened  in  the  right  linea  semilunaris,  and  several  pints  of 
bile  and  pus  were  evacuated.  The  peritoneal  cavity  was 
washed  out,  and  drainage-tubes  placed  between  the  liver  and 
diaphragm,  into  the  right  kidney  pouch,  and  downwards 
towards  the  pelvis,  with  the  result  that  the  patient  recovered, 
and  is  now  in  perfect  health. 

I  have  also  had  another  case  in  which  a  gall-stone 
ulcerated  through  the  gall-bladder  and  extravasation  of  bile 
occurred  where  operation  was  followed  by  recovery. 

Case  412. — Mrs.  M.  T.,  aged  forty-seven,  admitted  to  the 
Leeds  General  Infirmary,  January  21,  1902.  Had  had 
spasms  for  years,  but  no  definite  attack  of  biliary  colic.  On 
January  17  the  patient  was  seized  with  acute  pain  in  the 
abdomen,  accompanied  by  vomiting,  shivering  attacks,  and 
jaundice.  The  pain  had  been  extremely  severe,  accom- 
panied by  evening  rises  of  temperature.  On  admission,  she 
was  deeply  jaundiced.  The  gall-bladder  was  enlarged  and 
extremely  tender,  and  the  abdominal  walls  rigid. 


120    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation  January  23,  1902. — On  opening  the  peritoneum 
a  quantity  of  bile  escaped,  and  a  cavity  was  exposed  bounded 
above  by  the  liver  and  gall-bladder  and  below  by  omentum 
and  adhesions.  The  cavity  contained  a  quantity  of  bile  and 
some  gall-stones.  The  fundus  of  the  gall-bladder  was  gan- 
grenous and  perforated.  Several  stones  were  removed  from 
the  gall-bladder  and  cholecystectomy  was  performed,  a  tube 
being  passed  into  the  cystic  duct,  through  which  bile  drained 
quite  freely.  The  patient  made  a  good  recovery,  and  was 
discharged  well,  March  12,  1902. 

A  case  of  perforation  of  the  gall-bladder  following  typhoid 
ulceration  successfully  treated  by  abdominal  section  is 
reported  by  Dr.  Monier  Williams  and  Mr.  Marmaduke 
Sheild  in  the  Lancet  for  March  2,  1895.  The  case  occurred 
in  a  married  woman,  aged  thirty-one,  who  was  submitted  to 
operation  on  the  fifty-first  day  of  the  disease,  when  the  gall- 
bladder was  found  to  be  rigid  and  thickened,  and  of  a  dark 
plum  colour,  with  a  sharply  circular,  sloughy  ulcer,  the  size 
of  a  threepenny  piece,  near  its  neck,  the  gall-bladder  con- 
taining about  \\  ounces  of  thick  offensive  pus.  The  abdomen 
was  washed  out,  the  distended  intestines  were  emptied  by 
puncture,  and  gauze  packing  with  drainage  adopted,  the 
result  being  a  complete  cure. 

In  rupture  of  the  gall-bladder  from  sudden  pressure, 
induced  by  straining  at  stool,  vomiting,  sneezing,  efforts  in 
parturition,  or  even  by  blows  over  the  hepatic  region,  there 
is  in  all  probability  in  the  greater  number  of  such  cases  a 
predisposition  to  rupture,  in  the  shape  of  thinning  by  ulcera- 
tion or  by  long-continued  distension,  otherwise  the  accident 
would  be  much  more  common. 

This  was  probably  so  in  the  case  reported*  by  Dr.  Willard, 
and  in  the  one  described  by  Mr.  Lane  in  the  Lancet  for 
March,  1894,  and  certainly  was  in  the  following  case,  which 
occurred  in  a  middle-aged  woman,  and  was  reported  by 
Dr.  G.  P.  Biggs  in  the  New  York  Hospital  Reports. 

The  onset  of  the  fatal  seizure  was  sudden,  and  accom- 
panied by  colicky  pains  in  the  upper  abdomen,  rapidly 
followed  by  signs  of  acute  general  peritonitis.  She  died  on 
the  fourth  da)-  of  her  illness. 

Tnuisactions,  American  Medical  Association,  1893. 


INFLAMMATORY  AFFECTIOXS  121 

At  the  autopsy  the  abdomen  was  found  to  be  greatly 
distended,  and  full  of  a  dark  brown,  bile-stained  fluid,  having 
a  slightly  faecal  odour,  the  peritoneum  being  covered  with 
fibrinous  exudation. 

Just  inside  the  orifice  of  the  common  bile-duct  a  large 
gall-stone  was  impacted,  and  at  the  junction  of  the  gall- 
bladder and  cystic  duct,  a  minute  oblique  perforation  was 
found  in  the  floor  of  an  old  ulcer.  The  cystic,  hepatic,  and 
common  ducts  were  all  much  dilated,  the  last  admitting  a 
cylinder  1  centimetre  in  diameter. 

The  muscular  wall  of  the  gall-bladder  was  hypertrophied, 
and  the  mucous  membrane  thickened  from  chronic  inflam- 
mation, while  near  the  outlet  there  was  a  superficial  ulceration. 

Predisposition  was  also  present  in  a  case  I  saw  with 
Dr.  Solly,  of  Harrogate,  of  an  aged  physician,  who  had  been 
aware  of  a  tumour  in  the  gall-bladder  for  many  years,  and 
which  occasionally  gave  him  severe  pain,  though  usually  it 
produced  no  inconvenience.  In  his  final  seizure  he  developed 
acute  peritonitis  and  rapidly  succumbed. 

Dr.  Solly  discovered  a  perforation  in  an  old  ulcer  in  the 
gall-bladder,  which  must  have  been  present  for  a  long  time. 
Numerous  gall-stones  were  also  found  in  the  gall-bladder 
and  cystic  duct. 

In  Case  241,  on  opening  the  abdomen,  there  was  found  a 
gall-stone  actually  partly  extruded  into  the  peritoneal  cavity, 
there  being  no  adhesions  between  the  gall-bladder  and  its 
surroundings  which  would  in  any  way  have  limited  the 
effusion,  so  that  had  operation  been  delayed  general  peri- 
tonitis must  have  speedily  ensued. 

Such  cases  show  conclusively  that  it  is  folly  to  permit 
patients  with  distended  gall-bladders,  even  though  symptoms 
be  only  occasionally  present,  to  go  unoperated  on.  We  know 
of  several  cases  where  patients  are  living  in  a  fools'  paradise 
owing  to  such  unsound  advice. 

A  careful  operation  in  these  cases  is  almost  devoid  of  risk, 
but  rupture  is  hazardous  in  the  extreme. 

Massage  in  cases  of  distended  gall-bladder  we  look  on  as 
the  height  of  folly,  though  it  has  been  advised  by  those  who 
should  know  better. 


122    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Attempts  to  force  impacted  calculi  onward  by  pressure  are 
well  calculated  to  rupture  the  thinned  wall  of  the  gall- 
bladder or  bile-ducts,  or  to  cause  perforation  through  the 
base  of  an  ulcer,  leading  to  extravasation  of  infective  matter 
into  the  general  peritoneal  cavity,  and  probably  to  fatal 
peritonitis. 

In  the  greater  number  of  cases,  perforation  occurs  slowiy, 
as  was  the  case  in  an  aged  woman  seen  with  Dr.  Chadwick 
a  few  days  before  her  death,  where  jaundice  had  been  present 
for  five  years,  and  at  the  autopsy  a  large  gall-stone  was  found 
lying  in  a  cavity  outside  of,  but  pressing  on,  the  common 
duct.  The  adventitious  cavity  was  shut  off  from  the  general 
cavity  of  the  peritoneum  by  adhesions  of  the  neighbouring 
viscera. 

Specimen  No.  1,596,  Middlesex  Museum,  shows  a  portion 
of  liver  with  the  gall-bladder.  In  a  sac  beneath  it  are  a 
number  of  calculi  which  have  escaped  through  a  perforation 
in  the  gall-bladder,  and  are  lying  in  a  cavity  formed  by 
peritoneal  adhesions. 

Specimen  No.  2,830,  Royal  College  of  Surgeons  Museum, 
shows  a  cyst  between  the  hepatic  and  cystic  ducts  containing 
a  calculus  adherent  to  both,  but  communicating  with  neither 
duct,  though  it  has  evidently  perforated  one  of  the  channels 

(Fig-  34)- 

Gall-stones    may   perforate   the    mucous    membrane    and 

become  encysted  in  the  wall  of  the  ducts,  as  in  a  case  I  saw 
with  Dr.  Bramwell,  of  Cheltenham.  After  the  removal  of 
several  stones  from  the  gall-bladder,  three  were  felt  in  the 
common  duct,  two  of  which  were  readily  removed  by  chole- 
dochotomy,  but  the  third  was  buried  in  the  wall  of  the 
duct,  and  could  only  be  extracted  through  a  second  incision 
(Case  No.  261). 

In  some  cases,  as  in  one  reported  in  the  Lancet  for  1893 
by  Mr.  C.  A.  Morton,  the  primary  perforation  may  lead  to 
the  formation  of  a  second  cavity  bounded  by  plastic  lymph, 
which  may  again  rupture,  and  lead  to  a  fatal  peritonitis. 
The  following  is  a  brief  account  of  the  post-mortem  appear- 
ances in  the  case  referred  to,  the  patient  being  a  woman 
of  sixty  :  '  The  body  was  well    nourished.      The   abdomen 


PLATE  XII. 


Fig.   34. — Adventitious   Sac  containing  Gall-stone   situated  between- 
Hepatic  and  Cystic  Ducts. 


(No.  2,830,  Royal  College  of  Surgeons  Museum.) 


To  face  p.  122.] 


IN  FLA  MM  A  TOR  Y  A  FFECTIONS  i 23 

was  distended,  and  on  opening  it  much  orange-coloured  fluid 
escaped,  and  general  recent  adhesive  peritonitis  was  dis- 
covered. Just  below  the  liver  was  a  cavity  the  size  of  an 
orange,  bounded  above  by  the  under  surface  of  the  liver, 
and  in  front  by  the  thin  margin  of  the  liver  and  the  omentum, 
which  had  been  adherent  to  it.  Below,  it  was  separated 
from  the  colon  by  much  thickened  tissue.  On  its  inner 
side  lay  the  omentum,  and  on  its  outer  side,  covered  by 
adhesions  between  the  liver  and  adjacent  parts,  lay  the  gall- 
bladder, which  opened  into  the  cavity  by  an  aperture  which 
would  admit  one  or  two  fingers.  The  wall  of  the  gall- 
bladder was  much  thickened,  and  several  stones  h  inch  in 
diameter  were  found  lying  in  it.  Where  the  omentum  had 
before  been  adherent  to  the  anterior  edge  of  the  liver,  form- 
ing the  anterior  wall  of  the  cavity,  it  had  become  detached, 
and  thus  the  bile  had  escaped  into  the  peritoneum,  and  set 
up  fatal  peritonitis.  No  doubt  at  one  time  the  gall-bladder 
containing  gall-stones  had  perforated  under  these  surround- 
ing adhesions,  and  thus  the  secondary  gall-bladder  had  been 
formed,  which  in  its  turn  had  finally  ruptured  into  the 
peritoneum.     The  gall-bladder  was  not  dilated.' 

Erdman  (Annals  of  Surgery,  June,  1903)  publishes  the 
following  case  of  perforation  of  the  gall-bladder  : 

Female,  aged  forty-six  years  ;  married,  mother  of  several 
children ;  passed  through  a  typical  prodrome,  which  was 
followed  by  a  five  weeks'  course  of  unquestionable  typhoid 
fever.  The  eruption,  although  scanty,  was  evident  and 
unmistakable.  Headaches,  enlargement  of  the  spleen,  char- 
acter of  stools,  abdominal  distension,  dry,  coated  and  fissured 
tongue,  delirium,  followed  by  manifestations  of  exhaustion, 
subsultus  tendinum,  and  carphologia,  presented  a  clinical 
picture  that,  even  without  the  typical  temperature,  as  shown 
by  the  chart,  could  be  taken  but  for  the  one  thing,  typhoid 
fever.  During  the  period  of  her  third  and  fourth  weeks  a 
left-sided  phlebitis  developed.  Two  attacks  of  pain  in  the 
back,  described  as  being  between  the  shoulder-blades,  were 
present  in  the  third  week,  but  at  no  time,  according  to  the 
chart,  were  there  any  other  symptoms  present  suspicious 
enough  to  call  any  attention  or  notice  to  the  gall-bladder. 


124    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Her  temperature  reached  a  normal  plane  at  the  close  of  the 
fifth  week.  On  October  21,  the  day  before  I  saw  her  and 
about  the  second  day  of  her  sixth  week,  convalescence  was 
sufficiently  advanced  to  allow  her  to  sit  up  in  bed.  On  the 
night  of  this  day,  at  ten  o'clock,  she  was  seized  with  a  severe 
pain  in  the  abdomen,  which  required  several  hypodermics  of 
one-fourth  grain  of  morphine  before  any  comfort  was  obtained. 
The  site  of  this  pain  was  not  specialized  as  to  its  onset  loca- 
tion when  I  saw  her.  She  suffered  considerable  shock,  and 
when  seen  by  me,  exactly  twelve  hours  after  the  onset  of 
pain,  presented,  in  addition  to  those  accompanying  a  pro- 
tracted illness,  the  following  symptoms :  anxious  counte- 
nance, pulse  120,  respiration  rapid,  temperature  1020  F., 
abdomen  somewhat  distended,  exquisitely  sensitive  all  over, 
but  more  marked  on  the  right  side. 

Although  rather  later  than  usual  for  a  perforation  of  the 
intestine,  it  was  concluded  best  to  explore  the  right  iliac 
fossa.  This  was  done  by  an  incision  through  to  right  rectus. 
Upon  incising  the  peritoneum  there  was  a  gush  of  bile- 
stained,  cloudy  fluid,  with  no  odour  and  no  food  particles, 
through  the  opening  in  the  abdominal  wall.  Our  tentative 
diagnosis  of  perforation  of  the  intestine  was  then  changed 
to  that  of  a  probable  perforation  of  the  duodenum  or  gall- 
bladder ;  at  the  same  time  all  the  small  intestines  were  care- 
fully gone  over  before  extending  the  incision.  Fully  a  pint 
of  bile-stained  fluid  was  sponged  out  during  the  process  of 
inspection  of  the  intestines  and  the  enlarging  of  the  incision. 
The  gall-bladder  and  duodenum  were  easily  exposed,  and  then 
it  was  seen  that  an  opening,  irregularly  circular,  fully  J  inch 
in  diameter,  was  present  in  the  lower  portion  and  inner 
aspect  of  the  gall-bladder  near  the  cystic  duct,  through  which 
clear  bile  was  flowing.  The  gall-bladder  on  its  outer  aspect 
presented  no  other  inflammatory  manifestations,  nor  was  it 
evident  that  it  had  been  enlarged  previous  to  the  perforation. 
The  mesentery  and  intestines  were  deeply  stained  with  bile 
and  were  very  friable,  the  peritoneum  tearing  upon  the 
gentlest  handling. 

I  decided  to  do  a  cholecystectomy.     This  was  very  easily 
accomplished,  the  hepatic  attachment  being  separated,  owing 


IN FLA  MM  A  TOR  Y  A  FFECTIONS  125 

to  the  very  friable  condition,  with  the  greatest  ease.  A  double 
catgut  ligature  was  passed  about  the  cystic  duct,  the  bladder 
excised,  and  the  mucous  membrane  presenting  in  the  stump 
brushed  with  pure  carbolic  acid ;  a  gauze  drain  leading  down 
to  the  stump,  and  also  a  gauze  packing  on  the  very  freely 
bleeding  hepatic  surface  from  which  the  gall-bladder  had 
been  removed,  was  employed.  The  peritoneal  cavity  was 
sponged  out  with  salt  solution  and  gauze  pads.  The  abdo- 
minal wall  was  then  closed,  except  at  the  point  of  exit  of  the 
drain  and  at  its  lower  angle,  where  another  gauze  drain 
passed  into  the  iliac  fossa  and  pelvis.  This  latter  drain 
was  removed  in  three  days.  The  drain  and  packing  in  the 
region  of  the  stump  were  removed  at  this  time,  but  another 
small  drain  was  placed  in  this  opening.  A  perfect  recovery 
and  complete  union  were  recorded  in  three  weeks.  Upon 
closer  investigation  after  the  operation  had  been  done,  we 
were  told  that  her  onset  of  pain  was  situated  at  or  about 
the  usual  surgical  location  for  gall-stone  colic,  and  that  the 
general  abdominal  pain  appeared  at  or  about  the  end  of  the 
sixth  hour. 

Upon  opening  the  gall-bladder,  two  small  stones,  so  small 
as  not  to  be  considered  factors  in  the  cause  of  the  ulceration, 
were  found.  The  mucous  membrane  presented  numerous 
small  ulceration  areas,  and  no  opening  was  found  to  corre- 
spond to  the  opening  seen  on  the  peritoneal  surface.  There 
was  a  small  ulceration  area,  about  the  size  of  the  head  of  an 
ordinary  pin,  in  the  mucous  membrane  at  a  point  almost 
directly  through  from  that  of  the  peritoneal  opening,  and, 
upon  passing  a  probe  into  this  opening,  it  was  found  to  pass 
obliquely  through  the  gall-bladder,  making  its  exit  through 
the  peritoneal  orifice,  giving  one  the  reverse  picture  of  the 
funnel-shaped  perforating  ulcer  usually  seen. 

Cultures  taken  from  the  contents  of  the  peritoneal  cavity 
and  from  the  gall-bladder  showed  the  colon  and  typhoidaJ 
bacilli. 

He  also  gives  a  record  of  thirty-four  cases,  with  four 
recoveries.  Of  these  thirty-four  cases,  twenty-seven  were 
not  operated  upon,  and  all  died.  Of  the  seven  cases  in  which 
an  operation  was  performed,  four  recovered  and  three  died. 


126    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Erdman  strongly  advocates  cholecystectomy,  and  does 
not  approve  of  cholecystotomy  or  of  repair  of  the  perforation 
by  suture. 

The  perforation  may  occur  into  adjoining  parenchymatous 
organs.  If  reference  be  made  to  the  list  of  cases,  it  will  be 
seen  that  on  several  occasions  gall-stones  have  been  removed 
from  cavities  in  the  liver  produced  by  ulceration  and  perfora- 
tion of  the  gall-bladder  or  bile-ducts,  and  direct  passage  of 
the  contents  into  the  liver  tissue.  (Cases  6,  27,  and  268  are 
examples.) 

In  such  cases  there  are  the  usual  signs  of  liver  abscess 
following  on  the  ordinary  symptoms  of  gall-stones,  which 
may  have  been  present  for  years. 

If  the  ulceration  and  perforation  occur  from  the  common 
duct  into  the  substance  of  the  pancreas,  acute  pancreatitis 
may  follow ;  or,  without  perforation,  an  infective  inflamma- 
tion may  pass  from  the  common  bile-duct  to  the  pancreas, 
as  in  a  case  reported*  by  Dr.  Kennan,  in  which  a  woman  of 
thirty-eight  died  of  collapse  after  two  days'  illness,  charac- 
terized by  epigastric  pain,  vomiting,  and  abdominal  disten- 
sion. A  post-mortem  examination  revealed  acute  pan- 
creatitis, with  a  large  number  of  stones  in  the  gall-bladder 
and  common  bile-duct,  one  of  the  concretions  protruding 
into  the  duodenum. 

The  following  case  is  a  good  example  of  acute  gangrenous 
pancreatitis  following  on  gall-stones,  in  which  operation  led 
to  complete  recovery  of  health  : 

Gall-stones — Acute  Pancreatitis. — Mr.  S.,  aged  fifty-eight,  seen 
with  Dr.  Nettle,  of  Liskeard,  Cornwall,  on  March  31,  1902. 

Previous  History. — For  some  six  years  the  patient  had  been 
subject  to  paroxysmal  attacks  of  acute  pain  starting  in  the 
right  hypochondrium  and  radiating  over  the  abdomen  and 
through  to  the  right  scapula,  the  attacks  being  accompanied 
by  vomiting  and  more  or  less  collapse.  On  several  occasions 
he  had  passed  small  gall-stones. 

About  ten  weeks  ago  he  was  seized  with  an  attack  which 
did   not,    as    usual,   yield    to    morphine;    the   liver   became 
enlarged  and  tender,  there  was  a  great  amount  of  flatulence 
*  British  Medical  Journal,  November  14,  1896. 


INFLAMMATORY  AFFECTIONS  127 

and  acidity,  and  a  feeling  of  discomfort  generally.  After 
this  seizure  he  had  ague-like  attacks  and  jaundice  of  varying 
intensity,  and  from  that  time  a  tumour  steadily  developed  in 
the  epigastric  and  right  hypochondriac  regions.  He  so 
rapidly  lost  flesh  and  strength  that  when  he  was  taken  into 
a  surgical  home  in  London  for  operation  he  was  so  feeble 
and  emaciated  that  it  was  questionable  whether  he  would 
be  strong  enough  to  bear  it.  Jaundice  was  well  marked,  and 
the  tumour  in  the  upper  abdomen,  which  was  tense,  tender, 
and  fluctuating,  was  still  enlarging.  He  had  had  diarrhoea 
six  times  a  day  for  several  days  before  admission,  and  the 
motions  were  pale  and  contained  fat.  Just  before  operation 
he  vomited  clear  fluid,  not  containing  bile. 

Operation,  April  5,  1902. — Pancreatic  cyst  exposed  between 
the  stomach  and  colon,  containing  four  pints  of  straw- 
coloured  fluid.  Inside  the  cyst  was  found  a  mottled  black 
slough  with  gray  patches,  2J  to  3  inches  long  by  i-J  inches 
broad,  and  \  inch  thick,  evidently  pancreas. 

Gall-bladder  and  ducts  contained  thirty  stones,  two  the 
size  of  walnuts ;  one  of  these  at  the  junction  of  the  cystic 
and  common  duct,  and  pressing  on  the  latter.  Cyst  of 
pancreas  and  gall-bladder  drained  by  separate  tubes,  with 
stomach  and  first  part  of  duodenum  between  them. 

On  being  put  back  to  bed  the  patient  was  quiet,  but 
vomited  frequently.  He  made  a  steady  recovery,  without  any 
untoward  symptoms,  and  left  for  home  on  May  2,  1902.  On 
March  3,  1903,  the  patient  was  the  picture  of  health,  and 
had  gained  i|  stones  in  weight.  He  told  me  that  the  gall- 
bladder opening  had  closed  in  six  weeks  and  the  pancreatic 
fistula  in  nine  weeks.     Well  November,  1903. 

In  the  following  case  abscess  of  the  pancreas  resulted  from 
gall-stone  irritation  : 

Case  343. — Chronic  Pancreatitis  with  Abscess  associated  with 
Gall-stones — Cholecystotomy — Relief — Death  Four  Months  later 
from  Exhaustion — Autopsy. — Mr.  H.,  aged  forty,  seen  with 
Dr.  Woods,  of  Batley,  on  October  11,  1900.  The  patient  was 
then  deeply  jaundiced  and  extremely  ill,  suffering  from  con- 
tinuous fever  with  exacerbations,  great  debility,  and  extreme 
emaciation.     A  large  tumour  in  the  region  of  the  pancreas 


128    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

could  then  be  felt,  as  well  as  a  distended  gall-bladder.  He 
gave  the  history  of  failing  health  for  nine  months,  and  a 
history  of  gall-stone  attacks  and  painful  indigestion  for  some 
time  before  that ;  but  although  he  had  had  frequent  attacks  of 
abdominal  pain  for  three  or  four  months,  the  jaundice  had 
only  supervened  a  fortnight  before  my  seeing  him.  At  the 
operation  he  was  too  ill  to  bear  a  prolonged  search,  and 
there  were  numerous  adhesions  around  the  tumour,  which 
was  made  out  to  be  a  swelling  of  the  pancreas.  The  gall- 
bladder was  opened  and  drained  of  a  quantity  of  muco-pus. 
A  quantity  of  pus  was  discharged  from  the  drainage-tube 
several  days  after  operation,  and  this  was  repeated  on  two  or 
three  occasions  ;  the  pus  evidently  came  from  a  deeply-seated 
abscess  in  the  pancreas.  A  large  drainage-tube  having  been 
used,  there  was  a  free  discharge  of  bile,  and  a  considerable 
number  of  gall-stones  were  evacuated  through  it — thirty- 
three  in  all.  Previous  to  the  operation  the  patient  was 
suffering  from  shivering  attacks  and  a  persistently  elevated 
temperature,  which  subsided  immediately  after  drainage  was 
effected,  and  the  temperature  kept  nearly  normal  throughout 
the  remainder  of  his  illness,  it  being  normal  in  the  morning, 
though  there  was  usually  a  hectic  rise  each  evening.  He 
made  a  slow  though  apparently  steady  recovery  from  the 
operation,  and  the  pancreatic  tumour  diminished  so  rapidly 
that  it  was  confidently  believed  to  be  entirely  disappearing, 
it  being  only  one-third  as  large  as  at  the  time  of  operation. 
He  returned  home  on  December  14,  but  he  never  really 
picked  up  strength,  and,  though  there  was  no  further  eleva- 
tion of  temperature,  he  gradually  got  weaker  and  died  in 
February  from  exhaustion. 

At  the  post-mortem  examination,  made  by  Dr.  Woods,  a 
tumour  of  the  pancreas  was  discovered,  which  was  carefully 
examined  by  Mr.  Cammidge  and  pronounced  to  be  a  chronic 
inflammatory  tumour,  and  not  new  growth,  the  centre  being 
occupied  by  pulpy  material  where  the  abscess  had  originally 
been.  Nothing  else  was  discovered,  and  there  were  no  gall- 
stones left,  either  in  the  gall-bladder  or  ducts. 

Case  481. — Gall  stones  -  Abscess  of  Pancreas. — Mrs.  P.,  aged 
sixty-one,  seen  with  Dr.  Pemberton,  of  Burnley.     P^or  thirty- 


INFLAMMATORY  AFFECTIONS  129 

four  years  had  had  attacks  of  biliary  colic  from  time  to  time, 
but  had  never  been  jaundiced  after  the  attacks.  For  the 
last  two  and  a  half  years  had  been  subject  to  rigors,  accom- 
panied by  slight  epigastric  pain. 

Jaundice  always  present  more  or  less  during  the  last  two 
and  a  half  years,  but  deeper  after  the  ague-like  attacks  ;  pain 
never  severe.  On  examination,  the  liver  was  not  enlarged, 
and  there  was  no  distension  of  the  gall-bladder.  The  head 
of  the  pancreas  was  enlarged  and  tender. 

Operation,  January  19,  1903. — Hepatic  and  common  ducts 
packed  with  large  gall-stones.  Head  of  pancreas  much  en- 
larged, containing  cavity  filled  with  pus,  from  which  the 
largest  gall-stone  was  extracted.  Cholecystotomy,  chole- 
dochotomy.  Profuse  discharge  of  bile  and  offensive  pan- 
creatic fluid  with  pus  for  a  week.  The  patient,  who  was 
extremely  ill  at  the  time  of  the  operation,  made  a  good 
recovery,  and  is  now  completely  well. 

If  the  ulceration  advance  towards  the  adjoining  hollow 
viscera,  stomach,  duodenum,  or  colon,  adhesions  as  a  rule 
form,  and  the  perforation  is  effected  quietly.  In  one  case  of 
this  kind,  seen  with  Dr.  Stewart,  after  a  history  of  chole- 
lithiasis, followed  by  severe  stomach  symptoms,  the  gall- 
stones were  vomited,  and  complete  recovery  followed. 

In  several  cases  we  have  known  large  gall-stones  to  ulcerate 
their  way  quietly,  and  to  perforate  the  intestine,  only  produc- 
ing serious  symptoms  from  mechanical  intestinal  obstruction. 
These  will  be  considered  in  detail  under  the  heading  of  Fistula 
and  Intestinal  Obstruction. 

Rarely  gall-stones  have  perforated  into  the  pelvis  of  the 
right  kidney,  producing  symptoms  of  renal  calculus. 

Not  infrequently  the  perforation  may  occur  after  adhesion 
to  the  parietal  peritoneum,  when  a  superficial  abscess  may 
follow,  discharging  gall-stones. 

Specimens  in  the  museums  show  that,  although  adhesions 
may  have  formed,  the  process  of  ulceration  into  a  neighbour- 
ing cavity  is  by  no  means  always  free  from  danger  of  perfora- 
tion into  the  general  peritoneal  sac. 

Specimen  No.  864  in  the  Charing  Cross  Museum  shows  a 

9 


130    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

gall-bladder  colic  fistula,  in  which  there  has  been  a  fatal 
perforation  into  the  peritoneum. 

Specimens  No.  1,676,  King's  College  Museum,  and  No. 
2,S28,  Royal  College  of  Surgeons  Museum,  show  gall-bladder 
duodenal  fistulas,  in  which  death  occurred  from  perforative 
peritonitis  after  the  gall-stones  had  passed  into  the  in- 
testine. 

There  is  also  another  danger,  which  should  by  no  means 
be  despised,  and  that  is  the  fear  of  absorption  of  toxins, 
with  subsequent  septicaemia  or  pyaemia. 

The  symptoms  of  perforation  of  the  bile  passages  are  those 
of  perforative  peritonitis  from  other  causes,  but  there  will 
usually  have  been  premonitory  symptoms  pointing  to  the 
origin  of  the  disease. 

A  sudden  pain  beneath  the  right  ribs  and  collapse,  usually 
succeeded  by  vomiting,  general  distension  of  the  abdomen, 
and  a  rapid  pulse,  form  the  prominent  features  of  the  disease. 

If  the  extravasation  is  extensive,  there  will  be  signs  of  free 
fluid  in  the  peritoneal  cavity. 

Jaundice,  if  not  present  before  the  accident,  usually  comes 
on  from  absorption  of  biliary  pigment  by  the  peritoneum, 
and  if  the  bowels  can  be  moved,  the  motions  will  usually  be 
clay-coloured. 

If  the  case  be  not  operated  on,  death  will  probably  ensue 
within  a  few  days  from  toxaemia  and  paralysis  of  the  bowels, 
though  in  some  of  the  cases  quoted,  life  was  prolonged  into 
the  second  or  third  week. 

Treatment. — In  these  cases  medical  treatment  is  useless, 
and  to  give  opium  for  the  relief  of  pain  so  disguises  the 
symptoms  that  a  fatal  sense  of  security  is  given  for  a  time, 
and  when  the  mistake  is  discovered  it  may  be  too  late  to 
operate. 

As  soon  as  it  is  clearly  made  out  that  perforation  has 
occurred,  or  even  if  it  be  suspected  that  such  is  the  case,  the 
abdomen  should  be  opened  in  the  right  semilunar  line. 

If  pus  and  bile  be  found,  they  should  be  rapidly  wiped 
away  with  gauze  or  wool  sponges,  and  if  the  extravasation  has 
gone  beyond  the  local  area  of  disease,  the  abdomen  should  be 
flushed  with  hot  sterilized  saline  solution. 


INFLAMMATORY  AFFECTIONS  131 

The  patient  may  be  too  ill  to  bear  a  prolonged  opera- 
tion, and  if  so,  free  drainage  will  probably  do  all  that  is 
necessary. 

In  draining,  it  should  be  borne  in  mind  that  the  right 
kidney  pouch  forms  a  distinct  peritoneal  pocket,  and  that 
a  drainage-tube  applied  through  a  stab  opening  in  the  right 
loin  affords  a  free  exit  for  extravasated  fluids  coming  from 
the  neighbourhood  of  the  gall-bladder.  If  the  whole  peri- 
toneal cavity  has  been  soiled,  a  puncture  above  the  pubes 
large  enough  for  a  tube  to  be  passed  into  the  pouch  of 
Douglas  may  be  an  advantage. 

If  the  patient  be  in  sufficiently  good  condition  to  permit 
a  search  for  the  rupture,  and  it  can  be  found,  it  may  be 
closed  by  fine  silk  or  catgut  sutures,  but  as  a  rule  it  will 
be  wise  to  open  and  drain  the  gall-bladder  at  the  same 
time. 

Should  marked  cholecystitis  be  found,  the  question  of 
cholecystectomy  may  be  worth  considering  ;  but  when  the 
patient  is  in  a  critical  condition  it  is  a  mistake  to  attempt 
too  much,  and,  as  a  rule,  cleansing  and  free  drainage  will  be 
all  that  are  necessary  or  advisable  at  the  time,  the  removal 
of  the  cause  being  left  until  the  patient  is  better  able  to  bear 
a  more  prolonged  operation. 

FISTULA  OF  THE  GALL-BLADDER  AND  BILE-DUCTS. 

Fistulas  in  connection  with  the  bile  passages  are  by  no 
means  uncommon,  and  their  variety  is  considerable.  They 
result  from  operation,  or  from  disease,  and  in  the  latter  case 
they  are  due  to  ulceration  resulting  from  gall-stones  or 
cancer. 

The  fistulous  channel  may  either  be  direct  or  indirect,  in 
the  former  being  caused  by  an  advancing  ulcer  setting  up 
local  peritonitis,  and  causing  adhesion  of  the  gall-bladder  or 
bile-ducts  to  one  of  the  neighbouring  hollow  viscera,  or  to 
the  parietal  peritoneum.  The  extension  of  the  ulcer  con- 
tinuing, a  communication  is  established  with  the  contiguous 
channel  or  with  the  surface.  In  the  indirect  variety  the 
perforation   occurs  first  into  an  adjoining   parenchymatous 

9—2 


132    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

organ  or  into  a  localized  abscess,  and  then  into  an  adjacent 
hollow  viscus,  or  on  to  the  surface  of  the  body  at  some  part. 

A  fistula  may  also  arise  from  a  local  abscess  forming  out- 
side the  biliary  passages  around  the  primary  focus  of  in- 
flammation, and  then  bursting  into  the  adjoining  cavities, 
which  are  thus  made  to  communicate. 

Although  the  establishment  of  a  fistula  is  at  times 
dangerous,  and  at  others  excessively  annoying  or  uncomfort- 
able, in  many  cases  it  forms  one  of  Nature's  methods  of 
relief,  and  the  surgeon,  in  forming  a  permanent  biliary  fistula 
in  otherwise  incurable  jaundice,  or  in  making  an  anastomosis 
between  the  bile  passages  and  the  intestine  for  the  like 
purpose,  is  taking  a  leaf  from  Nature's  book. 

Many  of  the  fistulas  are  mere  pathological  curiosities,  quite 
undiagnosable,  and  only  capable  of  being  discovered  post- 
mortem. Many  must  form  and  heal,  leaving  the  patient 
cured,  and  thus  not  only  are  they  not  discovered,  but  they 
are  probably  not  even  suspected  ;  for,  contrary  to  what  one 
might  suppose,  fistulas  between  the  bile  passages  and  other 
hollow  viscera  in  the  majority  of  cases  heal  spontaneously, 
leaving  only  visceral  adhesions  ;  so  that  the  fistulas  are 
comparatively  rarely  found  post-mortem. 

It  will  thus  be  seen  that  the  elaborate  figures  given  by 
Courvoisier*  and  Naunyn  can  only  give  a  very  imperfect 
estimate  of  the  frequency  of  these  fistulas,  which  must  be 
constantly  overlooked  or  not  recorded. 

The  authors  named  examined  all  the  published  cases,  with 
the  following  results  : 

Fistulas  between  the  biliary  passages  themselves   ...  8 

,,  ,,  ,,  ,,  and  the  stomach  12 

,,  ,,  stomach  and  the  liver  ...     4 

m  „  »  „       gall-bladder  ..     8 

,,  ,,  biliary  passages  and  the  duo- 

denum   ...  ...  ...  108 

,,  ,,  duodenum  and  the  common 

bile-duct  ...  . ..    15 

,,  ,,  duodenum      and     the     gall- 

bladder ...  ...  •••93 

*  Beitrage  cur  Pathologic  unci  Chirurgie  Gallcnwege. 


INFLAMMATORY  AFFECTIONS  133 


Fistulae  between  th 

s  jejunum  and  the  gall-bladder... 

1 

)>                        5J 

ileum            „                  ,, 

1 

5>                        »> 

biliary  passages  and  the  colon . . . 

5° 

55                         55 

colon  and  the  gall-bladder      ...  49 

5)                          55 

colon  and  the  common  bile- 
duct        ...              ...              ...      1 

5?                        5) 

biliary     passages     and     the 

urinary  organs 

6 

5)                    55 

biliary  passages  and  thoracic 

organs    ... 

10 

5)                        55 

biliary    passages    and    abdo- 

minal walls 

184 

55                        J) 

biliary    passages    and    retro- 

peritoneal tissues  ... 

4 

Total      ...  ...  ...  384 

Out  of  a  table  of  10,866  autopsies  made  by  Roth,  Schroder, 
and  Schloth,  biliary  fistulae  occurred  forty-three  times  : 


Between  the  biliary  passages  themselves 

1 

55 

gall-bladder  and  liver  ... 

1 

55 

,,             ,,       stomach 

1 

5) 

,,             ,,       duodenum 

..      19 

55 

,,              ,,       colon ... 

..      16 

55 

common  bile-duct  and  the  duodenum 

••       5 

Total 

••     43 

It  would  be  of  greater  value  if  we  could  give  statistics  of 
the  number  of  times  that  fistula  follows  operation,  but  this 
is  seldom  mentioned  by  operators. 

The  operations  appended  below  extend  to  536  cases,  of 
which  416  were  cholecystotomies.  In  18  cases  there  were 
fistulae  following,  but  as  5  occurred  in  the  first  ten  opera- 
tions, since  which  time  the  method  of  procedure  has  been 
altered,  it  is  fairer  to  say  that  13  occurred  in  406  cases. 

Several  of  the  fistulae  were  inevitable,  as  the  ducts  were 
strictured ;  in  others  they  were  intentional,  as  in  cancerous 
obstruction  producing  jaundice.  Where  the  patients  lived — 
i.e.,   where    the    obstruction    was    due    to    simple    and    not 


134    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

malignant  disease — they  were  for  the  most  part  treated  by 
further  operative  measures. 

Biliary  Cutaneous  Fistula. — Courvoisier's  statistics  gathered 
from  reported  cases  would  seem  to  prove  that  this  is  the 
commonest  form  of  fistula.  It  may  be  pathological  or  post- 
operative. 

(a)  Post-operative  fistulae  may  be  mucous  or  biliary. 

Mucous  fistula?  are  occasionally  seen  after  the  operation  of 
cholecystotomy,  where  the  obstruction  in  the  cystic  duct  has 
not  been  overcome,  or  where  that  duct  is  the  seat  of  stric- 
ture. In  Case  i  the  patient  has  had  so  little  inconvenience 
that  she  does  not  think  it  worthwhile  to  undergo  any  further 
treatment. 

In  two  other  cases  of  mucous  fistula  (Cases  22  and  65)  de- 
pendent on  stricture  of  the  cystic  duct,  the  gall-bladder  was 
removed,  and  this  effected  a  complete  and  permanent  cure. 

In  another  case,  where  a  muco-purulent  fistula  had  been 
discharging  at  the  umbilicus  for  some  months,  the  channel 
was  followed  up  to  the  gall-bladder,  and  the  cystic  duct  found 
occluded  by  calculi,  which  were  subsequently  removed,  when 
the  fistula  closed  without  difficulty  (Cases  No.  79  and  109). 

A  mucous  fistula,  as  a  matter  of  fact,  causes  very  little 
inconvenience,  as  only  about  1  ounce  of  fluid  is  discharged 
daily ;  but  if  the  opening  be  allowed  to  close,  the  accumula- 
tion produces  pain,  and  it  is  therefore  necessary  for  a  patient 
under  these  circumstances  either  to  wear  a  small  tube  and  a 
pad  of  absorbent  wool  or  to  submit  to  operation. 

The  operation  of  cholecystotomy  will  not  be  followed  by 
fistula  (except  in  the  case  of  stricture)  if  the  bile-ducts  have 
been  cleared,  and  if  the  opening  in  the  gall-bladder  be 
sutured  to  the  aponeurosis  and  not  to  the  skin.  Since  the 
operation  of  cholecystotomy  was  modified*  in  this  way — 
which  was  done  after  Case  10 — no  fistula  has  followed  when 
the  bile-ducts  have  been  cleared. 

Biliary  fistula  following  on  operation  is  quite  a  different 
matter  from  mucous  fistula,  as  although  in  some  cases  it  is 
compatible  with  good  health,  the  inconvenience  caused  by 
30  ounces  of  bile   flowing  from  the  fistula  daily  produces 

*  This  was  first  suggested  and  carried  out  by  the  author,  May  2,  1889. 


INFLAMMATORY  AFFECTIONS  135 

so  much  discomfort  that  in  all  the  cases  which  have  come 
under  our  notice  the  patients  have  preferred  to  accept  the 
risks  of  operation  rather  than  to  retain  their  disability. 

The  treatment  of  biliary  fistula  should,  where  possible,  be 
effected  by  removing  the  cause ;  but,  as  in  certain  cases  this 
is  impracticable  or  impossible,  other  means  have  to  be 
considered. 

If  the  ducts  be  clear,  and  the  fistula  be  small,  the  applica- 
tion of  the  actual  cautery  to  the  margin  of  the  fistula  will 
frequently  result  in  its  closure.  That  failing,  the  method 
adopted  in  Case  116  may  be  followed,  of  opening  the  abdomen, 
detaching  the  gall-bladder,  and  suturing  the  opening. 

Or  the  less  severe  method  may  be  first  tried,  of  dissecting 
the  fistula  from  the  skin  margin,  without  opening  the  peri- 
toneum, afterwards  doubling  in  the  mucous  edges,  suturing 
them  accurately,  and  over  this  applying  one  or  two  layers  of 
buried  sutures  before  bringing  together  the  skin. 

Where,  however,  the  ducts  cannot  be  cleared,  and  the 
gall-bladder  is  large  enough  to  permit  of  it,  the  operation  of 
cholecystenterostomy  may  be  performed. 

This  operation  was  first  performed  in  a  case  of  biliary 
fistula  (Case  No.  13)  on  January  14,  1888,  and  the  patient  is 
at  the  present  time  in  excellent  health,  doing  duty  as  a 
maternity  nurse.     Case  121  is  another  good  example. 

If  the  fistula  be  dependent  on  gall-stones  or  fragments  in 
the  ducts,  the  ducts  may  be  syringed  through  daily  with 
olive  oil,  or  with  a  0*5  per  cent,  solution  of  sapo  animalis,  as 
recommended  by  Dr.  Brockbank ;  or  a  solution  of  turpentine 
in  ether  may  be  used,  as  in  Case  No.  23. 

This  is  easily  done  by  employing  a  small  flexible  catheter, 
which  is  passed  through  the  fistula  as  far  as  it  will  go  with- 
out force.  To  the  end  of  this  a  syringe  is  affixed,  and  the 
medicament  steadily  syringed  directly  on  to  the  obstruc- 
tion, the  syringing  being  repeated  night  and  morning  for  a 
time. 

After  some  experience  of  this  method,  I  am  compelled  to 
say  that  it  is  very  disappointing,  and  as  a  rule  it  will  be 
necessary  to  perform  a  further  operation  for  the  removal  of 
the  cause. 


136    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

(6)  Pathological  surface  fistulae  usually  open  at  the  umbilicus, 
the  abscess  following  the  course  of  the  remains  of  the  um- 
bilical vein,  as  in  Case  79,  but  they  may  form  at  any  part  of 
the  abdominal  wall,  even  near  the  pubes,  or  on  the  left  side 
of  the  abdomen. 

Calculi  of  various  sizes  and  numbers,  from  a  single  one 
3  inches  in  diameter,  reported  by  Gutteridge,*  to  multiple 
small  faceted  concretions,  the  size  of  shotcorns,  may  be  dis- 
charged in  this  way,  leading  to  recovery  and  permanent  cure, 
but  until  all  the  calculi  are  discharged  the  fistula  is  liable  to 
remain  open. 

In  operating  on  these  cases,  it  is  advisable  to  purify  the 
fistula  as  far  as  possible,  and  to  scrape  away  all  granulations 
before  opening  the  peritoneal  cavity  to  get  at  and  clear  the 
bile-ducts.  By  adopting  these  precautions  no  untoward 
results  are  likely  to  occur. 

Biliary  intestinal  fistulae,  as  might  be  expected  from  the 
contiguity  of  the  gall-bladder  to  the  duodenum  and  colon,  are 
the  most  common,  and  as  a  rule  they  are  due  to  ulceration 
produced  by  gall-stones.  Usually  the  ulceration  proceeds 
quietly  and  produces  very  few  symptoms,  until,  it  may  be, 
the  gall-stone  sets  up  obstruction  in  its  passage  down  the 
intestinal  canal,  or  after  the  formation  of  the  fistula  all  the 
symptoms  of  gall-stones  may  pass  away,  and  the  patient 
make  a  complete  recovery.  If,  however,  any  gall-stones 
have  passed  into  the  cystic  or  common  ducts,  the  symptoms 
are  likely  to  recur  as  the  fistula  contracts.  The  case  of  Mr.  I., 
related  on  p.  114,  is  an  example. 

Doubtless  in  that  case,  after  the  serious  illness  associated 
with  fever  and  local  peritonitis,  some  gall-stones  had  ulcerated 
their  way  from  the  gall-bladder  into  the  duodenum,  and  had 
been  passed  at  stool,  leaving  a  fistula,  which  drained  the 
infected  bile  into  the  bowel,  and  so  saved  the  patient  from 
infective  cholangitis,  for  at  the  same  time  other  gall-stones 
had  passed  into  the  common  duct  and  obstructed  it. 

So  long  as  the  gall-bladder  duodenal  fistula  was  open  no 
serious  harm  resulted,  but  when  the  opening  tended  to  heal 
and  close  (at  the  time  of  operation  it  would  only  admit  the 

*  Lancet,  18/8   vol.  i.,  p.  851. 


IN  FLA  MM  A  TOR  Y  A  FFECTIONS  i  V 

passage  of  a  small  probe)  the  infected  bile  was  unable  to 
escape,  and  was  retained  in  the  ducts  within  the  liver,  setting 
up  symptoms  of  infective  cholangitis,  as  well  as  chronic 
pancreatitis,  from  the  same  condition  applying  to  the  duct  of 
the  pancreas. 

The  closure  of  the  fistula  into  the  duodenum,  with  the 
removal  of  the  gall-stones,  the  ablation  of  the  gall-bladder, 
and  the  drainage  of  the  hepatic  duct,  effected  a  cure,  and  the 
patient  is  now  well. 

The  process  of  ulceration,  though  at  times  performed 
quietly  and  without  serious  illness,  is  not  always  accom- 
plished without  symptoms,  such  as  pain  over  the  liver,  more 
or  less  jaundice,  and  fever  of  an  irregular  type,  to  be  subse- 
quently followed  by  signs  of  more  or  less  complete  obstruc- 
tion of  the  bowel. 

Haemorrhage  into  the  stomach  or  intestines  may  occur  in 
these  cases. 

If  the  fistula  is  between  the  gall-bladder  and  duodenum, 
'  the  most  common  variety,'  the  whole  length  of  the  intestinal 
canal  has  to  be  traversed  by  the  concretions  ;  hence  such 
cases  are  found  to  be  more  frequently  associated  with 
obstruction  than  when  the  fistula  is  between  the  gall-bladder 
and  colon,  for  in  the  latter  case  the  passage  to  the  anus  is 
usually  accomplished  without  difficulty,  though  occasionally 
the  concretions  may  lodge  and  cause  trouble. 

When  a  gall-stone  is  impacted  in  the  common  duct  just 
before  entering  the  duodenum,  ulceration  and  perforation  of 
the  duct  are  apt  to  occur,  the  concretion  thus  escaping  into 
the  duodenum  by  an  enlargement  of  the  ostium  of  the 
common  bile-duct  from  ulceration  or  sloughing. 

Roth,  who  has  paid  special  attention  to  this  condition, 
found  it  five  times  in  twenty-five  cases  of  biliary  fistula. 

These  gall-stones  are  usually  smaller  than  those  causing 
gall-bladder  intestinal  fistula,  are  seldom  larger  than  filberts, 
and  do  not  often  cause  intestinal  trouble. 

Nearly  all  the  museums  have  in  them  examples  of  gall- 
bladder duodenal  fistula.  Specimens  Nos.  2,827  and  2,828 
in  the  College  of  Surgeons  Museum  are  good  examples. 

No.  2,826  shows  a  gall-stone  in  the  act  of  extrusion,  and 


138    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

it  will  be  seen  that  the  margins  of  the  opening  are  ulcerating 
to  allow  of  the  passage.  Death  occurred  after  six  weeks  of 
suffering  (Fig.  35). 

No.  1,399  m  Guy's  Museum  is  a  specimen  of  Dr.  Hale 
"White's,  showing  a  gall-bladder  duodenal  fistula  1  inch  from 
the  pylorus,  large  enough  to  admit  the  finger  ;  and  33  inches 
above  the  ileo-caecal  valve  is  a  large  gall-stone  impacted  in 
the  ileum. 

Xos.  2,261  and  2,262  in  St.  Bartholomew's  Museum  show 
gall-bladder  duodenal  fistula?. 

No.  1,676  in  King's  College  Museum  shows  a  gall-bladder 
duodenal  fistula.  Death  occurred  from  peritonitis,  though 
the  gall-stone  had  passed  per  anum. 

No.  1,595  in  the  Middlesex  Museum  shows  a  gall-bladder 
duodenal  fistula,  through  which  gall-stones  passed.  Death 
occurred  from  intestinal  obstruction. 

Gall-bladder  colic  fistulae  are  less  common  in  the  museums, 
probably  because  they  do  not  often  cause  death.  There 
are,  however,  a  sufficient  number  of  examples  to  show  that 
even  this  method  of  discharging  gall-stones  is  not  altogether 
safe. 

Specimen  No.  2,8o9A  in  the  Royal  College  of  Surgeons 
Museum  is  an  example  of  gall-bladder  colic  fistula  caused  by 
carcinoma  (Fig.  32,  p.  112). 

No.  1,589  in  the  Middlesex  Museum  shows  a  gall-bladder 
colic  fistula  from  a  woman  of  sixty.  Death  occurred  from 
cancer  of  the  uterus,  though  five  months  previously  she  had 
had  violent  abdominal  pain  accompanied  by  retching,  indi- 
cating the  time  the  fistula  formed  (Fig.  36). 

No.  864  in  the  Charing  Cross  Museum  shows  a  gall- 
bladder colic  fistula,  with  secondary  perforation,  and  death 
from  peritonitis.     Case  304  is  an  example. 

Biliary-gastric  fistula  is  less  common  than  might  be  thought, 
for  the  pylorus  is  not  infrequently  adherent  to  the  gall- 
bladder. I  saw  a  case  of  this  nature  in  which  the  vomiting 
of  gall-stones  made  the  diagnosis  probable,  though  the  com- 
plete recovery  of  the  patient,  a  woman  of  fifty,  rendered 
it  impossible  to  be  absolutely  certain  that  the  surmise  was 
correct. 


PLATE  XIII. 


Fig.  35. — Gall-stone  in  Act  of 
extrusion  into  duodenum,  the 
Edges  of  the  Opening  being 
Ulcerated. 

(No.  2,826,  Royal  College  of 
Surgeons  Museum.) 


To  face  p.  138.] 


Fig.  36. — A  Portion  of  Liver  with 
Gall-bladder  and  a  Piece  of 
the  Transverse  Colon. 

The  gall-bladder  is  much  elongated 
and  narrowed  ;  its  fundus  is  ad- 
herent to  the  transverse  colon, 
and  communicates  with  it  by  a 
circular  orifice. 

(No.  1,589,  Middlesex  Museum.) 


INFLAMMATORY  AFFECTIONS  139 

A  second  case  (No.  219)  is  of  great  interest,  as,  besides 
the  symptoms  of  recurring  pain  depending  on  gall-stones,  the 
patient,  a  lady,  aged  sixty,  suffered  from  constant  dyspepsia, 
with  frequent  vomiting  and  steady  loss  of  flesh.  At  the 
operation  the  stomach  was  found  firmly  adherent  to  the 
gall-bladder,  and  on  separating  the  adhesions,  a  fistula 
between  the  gall-bladder  and  stomach  was  found.  The 
edges  of  the  ulcer  in  the  stomach  were  pared,  and  the 
opening  closed  with  two  rows  of  sutures ;  while  the  opening 
in  the  gall-bladder  was  utilized  for  removal  of  the  gall-stones 
and  afterwards  for  drainage.  The  patient  made  an  excellent 
recovery,  and  is  now  in  good  health. 

The  Middlesex  Museum  has  a  specimen  of  gall-bladder 
stomach  fistula  (No.  1,595). 

Murchison  was  of  opinion  that  all  vomited  gall-stones 
must  have  entered  the  stomach  through  a  fistula. 

In  one  case,  Jeaffreson*  found  such  a  fistula  post-mortem, 
a  gall-stone  having  been  vomited  some  time  before.  Mr. 
Page's  case,  previously  referred  to,  is  an  example. 

No.  1,706*,  King's  College  Museum,  is  a  specimen  from  a 
case  which  died  seven  to  eight  weeks  after  gall-stones  were 
removed  from  the  pleural  cavity  by  Professor  Rose,  but  no 
communication  was  found  after  death  between  the  gall- 
bladder and  pleura. 

Of  the  rarer  forms — biliary  urinary,  biliary  vaginal,  biliary 
thoracic,  biliary  pulmonary,  biliary  pericardial,  biliary  medi- 
astinal, biliary  pleural,  biliary  retroperitoneal,  biliary  portal, 
hepato-gastric — which  are  pathological  curiosities,  reference 
may  be  made  to  cases  collected  by  Courvoisier,  Naunyn, 
Murchison,  etc. 

I  have  recently  operated  successfully  on  a  biliary  pulmonary 
fistula  by  removing  the  cause  of  obstruction,  a  gall-stone  in 
the  hepatic  duct.     See  Case  508. 

KINKING  OF  THE  BILE-DUCTS. 

Cases  have  been  from  time  to  time  recorded  by  various 
authors,  of  obstruction  of  the  bile-ducts  caused  by  kinking 
or  bending  of  the  ducts.     Virchow  stated  that  in  prolonga- 
*  British  Medical  Journal,  May  30,  186S. 


140    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

tion  of  the  right  lobe  of  the  liver  (Riedel's  lobe,  corset  lobe) 
in  women,  he  had  seen  during  pregnancy  that  this  lobe 
became  folded  over  against  the  under  surface  of  the  liver, 
carrying  with  it  the  gall-bladder.  This  bending  of  the  gall- 
bladder had  caused  traction  on  the  bile-ducts,  occlusion  of 
the  lumen,  and  retention,  with  jaundice.  Courvoisier  mentions 
bending  of  the  cystic  duct  at  its  origin  as  a  cause  of  dis- 
tension of  the  gall-bladder.  He  further  mentions  that  the 
permanency  of  a  biliary  fistula  following  cholecystotomy 
with  normal  bile-ducts  may  be  due  to  traction  of  the  gall- 
bladder, causing  a  bend  at  the  upper  end  of  the  common 
duct,  so  that  the  hepatic  duct  is  in  a  line  with  the  cystic 
duct,  resulting  in  all  or  most  of  the  bile  passing  out 
through  the  fistula,  and  little  or  none  through  the  common 
duct. 

Case  116  was  probably  an  example,  for  there  was  nothing 
in  the  shape  of  organic  obstruction  to  account  for  the  fistula, 
which  was  readily  cured  by  a  simple  plastic  operation. 

Komitsky  reported  the  case  of  a  girl,  aged  twenty-one, 
upon  whom  he  operated  for  a  supposed  hydatid  cyst  of  the 
liver  with  jaundice.  The  cyst  turned  out  to  be  an  immensely 
dilated  common  bile-duct,  which  was  stitched  to  the  surface 
and  drained  (choledochostomy).  The  patient  died,  and  at 
the  autopsy  it  was  found  that  the  condition  was  due  to  a 
bend  of  the  common  duct  at  the  point  where  it  enters  the 
wall  of  the  duodenum.  Komitsky  believed  that  this  bend 
caused  a  valve-like  occlusion  of  the  duct,  and  he  called 
attention  to  the  analagous  condition  of  valve  formation  in 
the  upper  end  of  the  ureter,  where  it  originates  from  the 
pelvis  of  the  kidney. 

Douglas,  in  1852,  found  the  following  condition  at  the 
autopsy  of  a  girl,  aged  seventeen,  who  had  suffered  from 
jaundice,  fever,  and  a  painful  tumour  in  the  right  hypo- 
chondrium.  The  common  duct  was  dilated  to  a  large  sac 
containing  half  a  gallon  of  offensive  bile.  The  walls  of  the 
sac  were  thickened  and  the  openings  of  the  hepatic  and 
cystic  ducts  dilated  so  as  to  permit  the  passage  of  a  finger. 
At  the  lower  end  of  the  large  sac,  towards  the  duodenum, 
there  was  a  small  opening  leading  into  a  normal  undilated 


INFLAMMATORY  AFFECTIONS  14 1 

duodenal  portion  of  the  common  duct,  at  the  upper  end  of 
which  a  sort  of  valve  was  found. 

Seiffert  also  reports  a  similar  case  to  the  above,  occurring 
in  a  woman  of  twenty-three. 

Those  cases  of  catarrh  of  the  gall-bladder  producing 
attacks  resembling  cholelithiasis  without  gall-stones,  but 
associated  with  movable  right  kidney,  probably  owe  their 
origin  to  kinking  of  the  bile-ducts  due  to  dragging  by  the 
displaced  kidney.  Case  45  is  an  example  in  which  cure  was 
effected  by  the  performance  of  cholecystotomy,  with  the 
subsequent  wearing  of  a  belt,  and  Case  525  is  another  example 
in  which  the  remedy  was  found  in  cholecystotomy  and 
nephropexy. 


CHAPTER  V 

INTESTINAL  OBSTRUCTION 

Intestinal  obstruction  from  gall-stones  is  such  a  distinct 
complication  of  cholelithiasis,  calling  for  special  treatment, 
that  it  will  not  be  beyond  our  province  to  consider  it,  and 
as  the  chief  variety  of  obstruction  is  necessarily  associated 
with  fistula  between  the  bile  passages  and  intestines  it  seems 
convenient  to  place  it  here. 

So  much  has  been  written  about  obstruction  from  gall- 
stones that  at  first  sight  it  might  seem  to  be  a  common 
ailment.  Such,  however,  is  not  the  case,  as  may  be 
gathered  from  the  fact  that  on  inquiring  of  the  registrars 
and  pathologists  it  was  found  that  only  four  such  cases 
had  been  treated  during  a  period  of  twelve  months  in  some 
of  the  largest  hospitals  in  the  kingdom,  representing  80,000 
in-patients  and  several  hundred  thousand  out-patients 
attended  to  during  the  same  time. 

Again,  only  one  case,  according  to  Dr.  Brockbank,  had 
occurred  in  the  Manchester  Royal  Infirmary  between  1883 
and  1896,  during  which  time  50,000  in-patients  had  been 
treated. 

Professor  Osier  ('  System  of  Medicine '),  quoting  Fitz, 
says  that  it  occurs  once  in  every  thirteen  cases  of  intestinal 
obstruction  (23  in  295  obstructions).  Leichtenstern  says 
once  in  every  twenty-eight  obstructions  (41  out  of  1,152). 
Mr.  H.  L.  Barnard,  quoting  from  the  statistics  of  the 
London  Hospital  ('  Annals  of  Surgery1)  for  eight  years,  says 
that  out  of  360  cases  of  intestinal  obstruction  there  were 
eight  cases  of  obstruction  from  gall-stones,  otherwise  one  in 
forty-five  cases. 

[  142  ] 


INTESTINAL  OBSTRUCTION  143 

There  are  clearly  four  classes  of  obstruction  of  the  intes- 
tines depending  primarily  on  gall-stones,  though  by  intestinal 
obstructions  from  gall-stones  is  usually  understood  the 
impaction  of  a  large  concretion  in  some  part  of  the  intestinal 
tract,  producing  a  mechanical  block. 

1.  Obstruction  depending  on  the  mechanical  occlusion  and 
the  injury  to  the  bowel  produced  by  the  passage  of  a  large 
gall-stone  along  the  intestinal  canal. 

2.  Obstruction  due  to  volvulus,  dependent  on  the  violence 
of  the  colic  caused  by  a  gall-stone  attack  or  induced  by  the 
passage  of  a  large  concretion  down  the  intestinal  canal. 

3.  Obstruction  depending  on  adhesions  left  after  local 
peritonitis  in  the  gall-bladder  region,  or  on  stricture  due  to 
the  healing  of  a  fistulous  opening  between  the  gall-bladder 
and  intestine. 

4.  Obstruction  dependent  on  local  peritonitis  in  the  gall- 
bladder region,  leading  to  paralysis  of  the  intestine. 

The  first  class  is  the  most  important  variety  of  obstruction 
dependent  on  gall-stones,  and  is  the  one  furnishing  not  only 
the  greatest  number  of  cases,  but  a  considerable  number  of 
museum  specimens.  It  is  dependent  on  the  mechanical 
obstruction  and  damage  to  the  bowel  produced  by  the 
passage  of  a  large  concretion  through  the  intestine  or  by 
its  impaction. 

Impaction  of  a  gall-stone  may  occur  at  any  point  in  the 
intestinal  canal,  though  it  happens  most  frequently  in  the 
small  intestines  at  or  near  the  ileo-csecal  valve.  As  the 
intestinal  canal  lessens  in  calibre  from  above  downwards, 
until  at  the  ileo-csecal  valve  the  narrowest  point  is  reached, 
we  may  expect  the  largest  gall-stones  to  produce  high 
obstruction  and  the  smaller  ones  to  pass  into  the  ileum  or 
to  the  valve  before  setting  up  any  disturbance. 

The  occurrence  of  obstruction  depends  not  only  on  the 
size  of  the  stone,  but  also  on  spasm  of  the  bowel  above  and 
below  the  obstruction,  and  on  inflammatory  changes  in  the 
wall  of  the  bowel  and  in  the  mucous  folds  ;  hence  it  follows 
that  obstruction  does  not  necessarily  follow  immediately  on 
the  entrance  of  the  calculus  into  the  lumen  of  the  gut,  but 
may  be  delayed  for  some  time,  possibly  even  for  weeks,  as  in 


144    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

some  of  the  cases  related  by  Karewski  (C entvalblatt  f.  Inn. 
Med.,  December  14,  1901  ;  abstracted  in  the  Medical  Review 
for  1902). 

Case  i. — A  man,  aged  fifty-six,  had  several  attacks  of 
biliary  colic  ;  in  the  last  there  was  faecal  vomiting.  Copious 
enemata  brought  away  a  stool.  Five  weeks  later  all  the 
symptoms  recurred,  and  were  again  removed  by  gastric  and 
intestinal  irrigation.  Pain,  however,  persisted  until  six 
months  later,  when  a  large  gall-stone  was  passed. 

Case  2. — A  woman,  aged  seventy-three,  who  in  youth  had 
suffered  from  '  cramps  in  the  stomach,'  was  suddenly  seized 
with  violent  pains  in  the  gastric  region  and  vomiting.  The 
vomited  matter  rapidly  become  feculent,  and  there  was  com- 
plete intestinal  obstruction.  Under  enemata  she  improved, 
but  pain  persisted  in  the  lower  abdomen.  Pyrexia  and  a 
palpable  swelling  appeared.  This  was  incised,  and  yielded 
pus  mixed  with  gas  and  a  large  gall-stone.  Convalescence 
was  prolonged  by  a  colic  fistula,  which  eventually  closed. 

Case  3. — A  woman,  aged  thirty-seven,  had  symptoms  of 
chronic  intestinal  obstruction  for  several  years,  which  occa- 
sioned acute  exacerbations.  The  diagnosis  lay  between 
chronic  cholelithiasis  and  the  results  of  perforation  of  a 
gastric  ulcer.  Laparotomy  was  performed.  Between  the 
matted  coils  of  intestines  was  an  abscess  containing  two 
gall-stones. 

Case  4. — A  woman,  aged  sixty,  had  suffered  for  twenty- 
two  years  from  pain  in  the  left  side  of  the  abdomen,  occa- 
sionally accompanied  by  bilious  vomiting.  There  had  never 
been  colic.  The  attacks  of  vomiting  became  more  and  more 
frequent,  and  finally  were  accompanied  by  intense  pain  and 
faecal  vomiting.  Faeces  and  flatus  were  still  passed.  Tempo- 
rary improvement  followed  gastric  and  intestinal  irrigation. 
Laparotomy  was  performed,  and  an  impacted  gall-stone  was 
removed  from  a  coil  of  small  intestine.  Faecal  vomiting  per- 
sisted for  thirty-six  hours  after  the  operation,  but  convales- 
cence was  thereafter  uninterrupted. 

In  a  paper*  I  read  before  the  Royal  Medical  and  Chirur- 
gical  Society  in  1894  were  related  notes  of  cases  illustrating 

*   Transactions  of  Royal  Medical  and  Chirurgical  Society,  1894. 


INTESTINAL  OBSTRUCTION  145 

this  condition.     The  following  case  is  quoted  in  extenso  from 
the  paper  : 

'  On  September  13,  1894,  I  received  a  telegram  from 
Dr.  Tempest  Anderson  and  Dr.  Raimes,  of  York,  to  go 
prepared  to  operate  on  a  case  of  acute  intestinal  obstruc- 
tion, but  on  arrival  word  was  brought  to  the  station  that  the 
patient  was  in  a  state  of  collapse,  and  might  be  dead  on  our 
reaching  the  house. 

'  Fortunately,  however,  we  went,  and  as  a  result  of  a 
morphia  injection  administered  by  Dr.  Raimes  before  our 
arrival  the  pulse  had  recovered  itself,  and  the  patient  was 
a  little  better.  She  was  a  lady  of  fifty,  and  gave  a  charac- 
teristic history  of  gall-stone  attacks  without  jaundice  for 
over  ten  years,  but  during  the  past  year  she  had  been  much 
better,  until  Saturday,  September  8,  when  she  was  seized 
with  violent  pain  in  the  centre  of  the  abdomen  of  a  colicky 
nature,  which  was  slightly  relieved  by  opium ;  the  pain, 
however,  soon  recurred,  and  was  accompanied  by  vomiting, 
which  became  faecal  on  Monday,  the  10th. 

1  Despite  morphia  and  other  means,  the  symptoms  per- 
sisted, and  on  Wednesday,  the  12th,  chloroform  was  admin- 
istered, and  abdominal  massage  with  abdominal  succussion 
was  employed,  but  without  relief. 

'  When  I  saw  her  at  10.30  on  the  evening  of  Thursday,  the 
13th,  her  pulse  was  rapid  and  intermittent,  and  she  looked 
extremely  ill,  though  she  was  temporarily  relieved  by  the 
morphia  which  had  been  given  a  little  time  before  our 
arrival. 

1  There  was  no  distension  of  the  large  bowel,  but  visible 
coils  of  small  intestine  pointed  to  some  obstruction  in  the 
lesser  gut,  and  we  all  agreed  that  operation  was  our  only 
course.  At  1  a.m.  on  September  14  the  abdomen  was 
opened  by  a  ii-inch  incision  below  the  umbilicus,  and 
almost  immediately  a  hard  lump  was  felt  inside  a  coil  of 
small  intestine  at  the  bottom  of  Douglas's  pouch.  This 
loop  was  brought  through  the  abdominal  incision,  and  sur- 
rounded by  gauze  wrung  out  of  carbolic  lotion. 

'  After  emptying  the  gut  by  pressure,  Dr.  Anderson 
grasped   the  proximal  and  distal   ends  between    his  fingers 

10 


146    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

and  thumbs.  I  then  incised  the  bowel,  and  the  stone  was 
extruded,  the  opening  in  the  gut  being  closed  by  a  continuous 
catgut  suture  for  mucous  membrane,  and  a  continuous  silk 
suture  for  the  serous  coat.  The  surface  of  the  bowel  which 
had  been  exposed  was  then  bathed  with  boracic  lotion  and 
returned,  and  the  abdominal  incision  closed  in  the  usual 
way. 

'  From  beginning  to  end  the  operation  occupied  but  twenty 
minutes,  and  the  patient  was  put  into  bed  in  much  better 
condition  than  she  was  in  before  the  operation.  The  wound 
healed  by  first  intention,  and  there  was  nothing  to  chronicle 
in  the  after-progress  of  the  case,  the  patient  being  now  quite 
well.  The  stone  weighed  i^  ounces  when  dry,  and  measured 
3  inches  in  circumference  in  one  direction,  and  4J  inches  in 
circumference  lengthwise.' 

The  following  eight  cases  from  the  records  of  the  London 
Hospital  (1893  to  1901),  reported  by  Mr.  H.  L.  Barnard  in 
the  Annals  of  Surgery,  1901,  are  of  great  interest : 

Case  i. — R.  F.,  woman,  aged  thirty-seven;  admitted 
January  13,  1901.  Good  health  up  to  nine  months  previous. 
No  biliary  colic,  no  jaundice,  no  obstruction.  During  last 
nine  months  suffered  from  aching  pain  in  right  hypo- 
chondrium.  Absolute  constipation  from  January  11  with 
vomiting ;  tenesmus ;  vomiting  incessant,  profuse,  and  ster- 
coraceous. 

On  examination,  little  distension,  no  tenderness.  Mass  felt 
in  Douglas's  pouch  taken  to  be  faecal. 

Operation. — Stone  found  impacted  5  feet  from  ileo-caecal 
valve ;  removed  through  incision  in  gut ;  wound  of  intestine 
closed  by  two  layers  of  sutures ;  abdomen  closed  without 
drainage.  Bowels  opened  on  second  day.  Recovery  un- 
interrupted. 

Measurements  of  Stone. — Length,  2.\  inches;  diameter, 
1 }  inches  ;  circumference,  3J  inches ;  weight,  294  grains. 

Case  2. — M.  M.,  woman,  aged  sixty-three  ;  admitted  June, 
1 90 1.  Clear  history  of  biliary  colic  for  years,  but  no  jaun- 
dice. Five  days'  abdominal  pain  with  vomiting,  the  latter 
being  feculent  ;  incomplete  constipation. 

Patient  in  bad  condition  (bronchitis)  ;  feeble  pulse  ;  no  dis- 


INTESTINAL  OBSTRUCTION  147 

tension,  and  very  little  tenderness  ;   no  tumour  felt  by  ab- 
dominal, vaginal,  and  rectal  examination. 

Diagnosis  of  impacted  gall-stone  in  intestine. 

Operation. — Stone  found  impacted  5  feet  from  valve.  Re- 
moved in  same  way  as  previous  case — suture  of  intestine  ;  no 
drainage. 

Death  twenty-four  hours  after  operation. 

Post-mortem. — Loculated  gall-bladder,  containing  several 
small  and  one  large  gall-stone  ;  fistula  between  gall-bladder 
and  second  part  of  duodenum  ;  common  duct  normal. 

Stone  removed  from  intestine  barrel-shaped  and  faceted  at 
both  ends.  Diameter,  J  inch  ;  circumference,  3  inches ; 
weight,  103  grains. 

Case  3. — I.  P.,  woman,  aged  sixty-eight,  admitted  Sep- 
tember 11, 1901.  Two  months'  illness,  with  severe  abdominal 
pain  and  jaundice.  Five  days  before  admission  severe  abdo- 
minal pain  and  profuse  vomiting  ;  absolute  constipation  for 
two  days.  Patient  collapsed  and  almost  pulseless.  Abdomen 
soft ;  no  distension  or  tenderness ;  no  tumour  to  be  felt  ;  no 
jaundice. 

Diagnosis  of  gall-stone  obstruction. 

Operation  (under  cocaine). — Ten  feet  from  valve  gall-stone 
impacted ;  removed ;  Paul's  tube  fastened  into  intestine. 
Death  in  forty-eight  hours. 

Post-mortem. — Large  ragged-edged  fistula  between  gall- 
bladder and  first  part  of  duodenum  ;  cystic,  hepatic,  and 
common  ducts  dilated ;  stone  impacted  in  common  duct. 
Calculus,  large,  rough,  barrel-shaped.  Length,  if  inches ; 
diameter,  1 J  inches  ;  weight,  234  grains. 

Case  4. — H.  G.,  woman,  aged  seventy-three,  admitted 
January  3,  1894,  under  Mr.  Openshaw.  Four  days  before 
admission  she  was  seized  with  sudden  paroxysmal  pain  in  the 
region  of  the  umbilicus,  and  this  had  persisted.  Vomiting 
constant  for  three  days  and  feculent.  Constipation  complete 
for  five  days.      Abdomen  a  little  distended  ;  no  tumour  felt. 

Operation. — Gall-stone  impacted  in  ileum  1  foot  from  the 
valve.  Intestine  thin  and  ulcerated ;  gall-stone  removed  by 
incision,  and  wound  closed  by  Lembert  sutures.  Death 
four  hours  later  ;  no  post-mortem. 

10 — 2 


1 48    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Case  5. — G.  S.,  male,  aged  forty-two,  admitted  March  19, 
1894,  under  Mr.  Eve.  Eighteen  years  before  severe  attack 
of  epigastric  pain,  accompanied  by  tenderness  and  vomiting. 
During  next  seven  years  attacks  of  pain  in  abdomen.  During 
next  ten  years  obstinate  constipation  with  dyspepsia.  (Mr. 
Eve  thinks  that  the  stone  was  in  small  intestine  during  this 
period.) 

Four  days  before  admission  severe  pain,  with  continuous 
vomiting  and  absolute  constipation,  appeared  suddenly. 
Under  anaesthetic,  hard  bullet-like  lump  felt  in  right  iliac 
fossa. 

Operation. — Gall-stone  impacted  at  ileo-caecal  valve  pushed 
up  into  ileum,  and  removed  through  incision  ;  wound  closed 
by  suture.  Recovery.  Length  of  calculus,  ij  inches;  dia- 
meter, 1  inch  ;  circumference,  3J  inches ;  weight,  190  grains. 

Case  6. — E.  S.,  woman,  admitted  November  6,  1895, 
under  Mr.  Jonathan  Hutchinson,  junr.  Clear  history  of 
attacks  of  jaundice  and  biliary  colic.  Four  days  before 
admission,  sudden  and  acute  pain  in  the  right  hypochondriac 
region,  with  vomiting,  continuous  and  latterly  feculent ; 
constipation;  slight  jaundice;  abdomen  tender  and  dis- 
tended. 

Operation. — Gall-stone  impacted  several  feet  above  ileo- 
caecal  valve.  Enterotomy  ;  three  stones  removed,  one  large 
and  two  small.  Wound  sutured.  Recovery.  Length  of  cal- 
culus, if  inches;  diameter,  1  inch;  circumference,  3J-  inches; 
weight,  191  grains. 

Case  7. — H.  S.,  male,  aged  fifty-two,  admitted  October 
26,  1898,  under  Mr.  McCarthy,  in  a  dying  condition,  on  tenth 
day  of  acute  obstruction.     No  operation. 

Post-mortem. — Large  gall-stone  impacted  in  ileum  25  inches 
from  caecum  ;  fistula  between  gall-bladder  and  duodenum. 

Case  8. — S.  N.,  woman,  aged  fifty,  admitted  November  27, 
1899,  under  Mr.  Openshaw.  Twelve  months  previously  had 
•re  attack  of  abdominal  pain,  accompanied  by  vomiting  ; 
six  or  seven  similar  attacks  during  the  year.  Present  attack 
commenced  ten  days  before  admission  with  '  spasms '  and 
sickness.  Distended  abdomen  ;  absolute  constipation  and 
feculent  vomiting. 


PLATE  XIV. 


J'1'--  37- — Large  Gall-stone  producing  Acute  Intestinal  Obstruction 

SUCCESSFULLY    REMOVED    BY    ABDOMINAL    SECTION. 

(No.  2,436a,  Royal  College  of  Surgeons  Museum.) 


•M9- 1 


INTESTINAL  OBSTRUCTION  149 

Operation. — Gall-stone  in  ileum.  Enterotomy  ;  stone  re- 
moved ;  wound  closed  by  sutures.  Death  forty-eight  hours 
later. 

Post-mortem. — Fistula  between  gall-bladder  and  first  part 
of  duodenum. 

Mr.  Lund  reported  a  case*  in  which  he  had  successfully 
removed  a  large  concretion  by  enterotomy.  The  interesting 
points  in  this  case  are  that  there  never  had  been  any  previous 
history  of  jaundice  or  colic,  nor  any  recollection  of  a  feeling 
of  uneasiness  in  the  region  of  the  gall-bladder.  The  obstruc- 
tion was  caused  by  a  gall-stone  fixed  in  the  ileum,  and  lying 
near  the  brim  of  the  pelvis.  The  measurements  of  the  gall- 
stone, which  was  the  shape  of  the  gall-bladder,  were :  Long 
diameter,  if  inches ;  transverse,  1  inch ;  longitudinal  cir- 
cumference, 4^-  inches  ;  transverse,  3 \  inches. 

Dr.  Everley  Taylor  reported  a  successful  operation  in  the 
Lancet,  and  the  very  large  gall-stone  removed  is  in  the  Hun- 
terian  Museum,  No.  2,436a  (Fig.  37). 

It  is  astonishing  how  few  unsuccessful  cases  are  reported, 
yet  we  know  that  the  mortality  of  these  operations  has  been 
considerable.  The  following  case  {British  Medical  Journal, 
March  9,  1895),  reported  by  Dr.  Kinneir,  of  Horsham,  is 
worth  noting : 

Mrs.  B.,  aged  fifty-seven,  was  taken  with  sudden  abdominal 
pain,  followed  by  sickness,  on  January  14.  On  the  following 
morning  she  passed  two  loose  motions.  The  sickness  con- 
tinued, and  stercoraceous  vomiting  commenced  on  January  17. 
Dr.  Kinneir  was  called  in  to  see  the  patient  on  January  20 
by  the  family  medical  attendant,  and  performed  laparotomy 
on  January  21.  He  found  a  large  gall-stone  impacted  in  the 
upper  part  of  the  ileum,  which  he  removed  by  enterotomy. 
After  the  operation  the  sickness  ceased  for  some  hours  ;  the 
patient  was  conscious,  expressed  relief,  and  took  some 
nourishment.  About  six  hours  later  she  vomited,  but  not 
faecal  matter.  This  continued  at  intervals  during  January  22, 
and  on  the  morning  of  January  23  the  vomit  became  again 
stercoraceous  and  very  offensive.  She  died  on  the  afternoon 
of  that  day.     There  was  no  swelling  of  the  abdomen,  before 

*  Lancet,  July  II,  1896. 


150    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

or  after  the  operation,  and  very  little  pain ;  the  temperature 
was  normal  throughout. 

Very  little  urine  was  passed,  and  constipation  was  com- 
plete from  January  15,  in  spite  of  medical  treatment.  She 
passed  flatus  frequently  before  she  died.  After  the  operation 
she  was  fed  on  soda-water,  some  brandy,  and  nutrient  sup- 
positories. Morphine  was  injected  hypodermically.  The 
gall-stone  was  covered  with  a  layer  of  hard  faecal  matter. 
It  measured  1 J  inches  in  diameter  ;  its  weight  was  2|  drachms. 
On  section  it  presented  the  usual  striated  centre,  getting 
darker  towards  the  circumference. 

Post-mortem. — The  median  incision  had  begun  to  unite ; 
there  was  no  trace  of  peritonitis,  and  no  serum  or  fluid  in 
the  cavity.  The  wound  in  the  intestine  was  quite  un- 
changed ;  the  small  intestine  nearly  down  to  the  caecum  was 
distended.  There  was  no  other  sign  of  obstruction  from  the 
duodenum  to  the  anus.  The  mesentery,  at  the  seat  of  the 
obstruction,  and  the  intestine  itself,  were  of  a  dark  green 
colour. 

Sendler  (British  Medical  Journal  Supplement,  April  20, 
1901)  performed  abdominal  section  for  intestinal  obstruction, 
and  found  the  ileum,  at  a  point  about  8  inches  above  the 
ileo-caecal  valve,  totally  obstructed  by  a  gall-stone  of  the  size 
of  a  hen's  egg.  On  the  eighth  day  after  the  operation  a 
faecal  fistula  developed  in  the  abdominal  wound,  and  on  the 
tenth  the  patient  died  of  collapse.  No  trace  of  peritonitis 
could  be  detected,  but  a  minute  gap  was  found  in  the  line  of 
suture  in  the  ileum  at  the  point  where  it  touched  the 
abdominal  parietes. 

The  following,  among  other  cases  which  we  could  relate, 
will  serve  to  illustrate  the  passage  of  gall-stones  without 
operation,  after  causing  symptoms  of  intestinal  obstruction. 
On  August  26,  1895,  I  saw  with  Dr.  Lever,  of  Harrogate,  a 
lady  of  seventy-three,  suffering  from  acute  intestinal  obstruc- 
tion of  three  days,  with  faecal  vomiting  of  twenty-four  hours' 
duration.  As  there  was  a  previous  history  of  gall-stone 
attacks  years  before,  and  as  the  pain  of  the  present  attack 
started  over  the  hepatic  region,  it  was  decided  to  wait  and 
treat  the  case  medically,  with  the  result  that  a  large  gall- 


INTESTINAL  OBSTRUCTION  151 

stone  was  passed   naturally  after  two  days,  and  the  patient 
made  a  good  recovery. 

In  a  case  recorded  by  Dr.  C.  Martin  the  patient  suffered 
from  absolute  obstruction  for  six  days  ;  vomiting  was  severe 
and  finally  stercoraceous.  On  the  morning  of  the  seventh 
day  a  motion  was  passed,  followed  by  the  evacuation  of  a 
large  stone.  The  patient  rapidly  recovered.  The  concretion 
had  a  circumference  of  3  J  inches. 

Mr.  E.  W.  Palin's  case,  reported  in  the  Lancet  for  May  12, 
1  goo,  is  of  interest  as  illustrating  a  case  occurring  in  an  aged 
patient. 

A  woman,  aged  eighty  years,  was  suddenly  seized  with 
symptoms  of  acute  intestinal  obstruction,  which  persisted  in 
spite  of  treatment  until  the  sixth  day,  when  complete  relief 
followed  the  passage  of  a  gall-stone  measuring  a  little  over 
1  inch  in  diameter  by  §  inch  in  thickness,  nearly  round, 
and  well  saturated  with  faecal  material.  Several  smaller  stones 
were  passed,  but  unfortunately  they  were  lost.  There  had  never 
at  any  time  in  the  patient's  life  been  any  symptoms  pointing 
definitely  to  gall-bladder  trouble,  but  she  passed  through  a 
very  similar  attack  of  obstruction  some  five  or  six  years  ago. 
Though  the  obstruction  was  complete  for  at  least  six  days, 
her  condition  never  became  extremely  bad.  Distension 
slightly  progressed  from  the  third  to  the  fifth  day,  but  was 
never  great.  She  did  not  suffer  from  shock.  The  pulse 
remained  fairly  strong  for  an  old  woman.  The  tongue  was 
dry,  but  not  brown.  Vomiting  was  never  faecal ;  incessant  at 
first,  it  latterly  diminished  in  frequency,  and  she  always  sat 
up  to  vomit. 

Israel  performed  laparotomy  in  a  case  of  intestinal  ob- 
struction, and  found  a  gall-stone  in  the  lower  ileum  with  a 
diameter  of  only  2  inches.  It  was  assumed  that  the  stone 
had  caused  a  '  dynamic  obstruction  '  by  spasm  (Treves, 
'  Intestinal  Obstruction,'  p.  194). 

The  following  notes  are  descriptive  of  a  case  in  the  prac- 
tice of  a  former  Leeds  house-surgeon,  Dr.  Wilkinson,  of 
Anerley  Hill : 

1  My  patient  is  a  lady  of  sixty-three,  and  the  facts  are, 
briefly:   An   attack  of   biliary  colic,   followed  by   symptoms 


152    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

of  acute  intestinal  obstruction,  stercoraceous  vomiting,  etc. 
Obstruction  lasted  three  weeks,  giving  way  finally  under 
rest,  opium,  and  copious  enemata ;  and  three  weeks  later  a 
gall-stone  was  passed  per  vias  naturales,  about  the  size  of  a 
pigeon's  egg,  and  weighing  5  drachms  414  grains.  There 
was  a  well-marked  facet  on  the  stone,  and  the  patient  had 
only  the  faintest  tinge  of  jaundice.' 

In  the  Leeds  Museum  are  stones  from  a  case  under  the 
care  of  the  late  Mr.  McGill,  in  which  the  calculi  (Fig.  39), 
four  in  number,  were  passed  after  causing  acute  obstruction. 

In  making  a  study  of  the  reported  cases,  and  especially  of 
museum  specimens,  one  cannot  help  feeling  astonished  at 
finding  fatal  obstruction  depending  on  quite  small  concre- 
tions, and  the  comparatively  easy  passage  of  very  large  gall- 
stones. 

For  instance,  side  by  side  in  Guy's  Museum  are  specimens, 
Nos.  1,456,  1,457,  1,458,  and  1,459,  showing  by  no  means 
large  calculi — one,  in  fact,  only  weighing  55  grains — all  of 
which,  nevertheless,  caused  fatal  obstruction  ;  and  specimens, 
Nos.  1,449,  ij45°)  and  1,451,  showing  large  stones  safely 
passed  per  anum,  though  in  one  case  the  stone  was  3J  inches 
in  circumference,  and  in  another  3  inches  long  and  1}  inches 
in  diameter. 

In  a  case  of  Dr.  J.  Blackburn's  the  stone,  3J  inches  long 
by  il  inches  broad,  actually  produced  no  symptoms  except 
when  at  the  anus.  The  gall-stone  is  in  the  Hunterian 
xMuseum,  No.  143A. 

In  the  Hunterian  Museum,  No.  2,436,  is  shown  a  beautiful 
specimen  of  a  gall-stone  weighing  400  grains,  and  measuring 
2  inches  by  i-\  inches,  taken  from  a  woman  of  fifty-two.  The 
fistula  between  the  gall-bladder  and  duodenum  through  which 
it  had  passed  into  the  bowel  is  also  shown. 

In  the  Middlesex  Museum  are  two  of  the  most  perfect 
specimens  of  the  kind  to  be  found  (Nos.  1,493  and  1,595). 
No.  1,493  shows  a  portion  of  the  middle  of  the  ileum 
(Fig.  40).  Impacted  in  it  is  a  large,  almost  spherical  gall- 
stone, nearly  4  inches  in  circumference.  It  has  been  sawn 
in  half,  and  the  upper  fragment  removed.  The  mucous 
membrane  of  the   intestine  corresponding  to  this  has  been 


PLATE  XV. 


B 


Fig.  38. 

A,  Drawing   of    gall-stone   weighing    238    grains,    causing    acute    intestinal 

obstruction,  removed  by  laparotomy  in  Guy's  Hospital.  Death  eight 
hours  after  operation.  (Paper  by  Mr.  Bryant,  Clinical  Society's  Trans- 
actions, vol.  xii.,  p.  106.) 

B,  Gall-stone  passed   after  five    days'    symptoms  of    obstruction.      Weight, 

228  grains. 


To  face  p.  152.] 


PLATE  XVI. 


D 


Fig.  38a. 

A,  A  gall-stone  which  was  voided  by  an  old  woman   after  a  nine  days'  severe 

illness.  It  weighed  160  grains ;  and  had  a  diameter  of  1  inch  and  two 
lines.  The  case  is  described  by  Dr.  Craigie  in  the  Edinburgh  Medical 
Journal,  vol.  xxii.,  p.  240.     A  synopsis  of  it  is  given  in  this  work. 

B,  C,  D,  are  given  to  illustrate  a  fatal  case  of  chronic  obstruction  by  gall- 

stones, and  at  the  same  time  the  great  difficulties  which  attend  diagnosis. 
The  patient,  a  woman,  aged  fifty-nine,  died  of  perforation  of  the  ileum, 
just  above  the  caecum,  eight  months  after  the  probable  date  of  escape  of 
the  stones  from  the  gall-bladder,  and  after  eight  weeks  of  incomplete 
obstruction.  The  symptoms  had  been  vomiting,  constipation,  and  severe 
griping  pain,  but  they  had  been  repeatedly  relieved  by  treatment  ;  the 
bowels  had  acted  well,  and  at  no  time,  until  the  last  few  days,  had  there 
been  abdominal  distension.  There  had  never  been  jaundice,  and  the 
patient  had  usually  enjoyed  fair  health.  Eight  months  before  her  death 
she  had  passed  through  an  attack  of  constipation,  with  great  pain,  and  at 
that  time  a  hard  tumour  could  be  felt  in  the  right  hypochondrium.  At 
the  autopsy  the  gall-bladder  was  healthy,  and  no  conditions  were  found 
which  threw  any  light  upon  the  mode  by  which  the  stones  had  escaped. 
Each  of  the  larger  stones  measured  about  4.  inches  in  circumference. 
There  was  no  proof  that  any  accretion  had  been  received  from  the 
contents  of  the  intestine. 

It  will  be  seen  that  in  this  case  no  permanent  obstruction  was  caused, 
and  that  for  months  together  the  bowels  acted  well.  Death  was  not  from 
obstruction,  but  from  perforation  from  ulceration.  The  fact  that  there 
were  several  stones,  and  some  small,  probably  conduced  to  this  result. 

The  case  is  recorded  by  Mr.  Le  Gros  Clark  in  the  Medico-Chirurgical 
Society's  Transactions.  It  is  republished  in  full,  with  other  important 
illustrations  of  gall-stones,  in  the  '  Pathological  Atlas  of  the  New 
Sydenham  Society,'  Fascic.  vii. 


To  face  p.  152.] 


PLATE  XVII. 


Fig.  39. — Large  Gall-stone 
producing  Acute  Intestinal 
Obstruction  passed  per 
Anum  as  Four  Separate 
Calculi,  with  Recovery  of 
the  Patient. 

(No.  317A,  Leeds  Museum.) 


Fig.  40. — Large  Gall-stone  im- 
pacted in  Ileum,  and  pro- 
ducing Fatal  Obstruction. 

(No.  1,493,  Middlesex  Museum.) 


To  face  p.  152.] 


INTESTINAL  OUSTRUCTION  J  53 

destroyed  by  ulceration.  The  intestine  above  the  obstruc- 
tion is  dilated.  Its  peritoneal  surface  is  partly  covered  with 
lymph.  The  gall-stone  had  passed  into  the  duodenum 
through  an  ulcerated  opening  between  it  and  the  gall-bladder. 

The  patient  was  a  woman,  aged  forty-six,  who  died  in  the 
hospital,  January  31,  1856.  Twelve  days  before  her  admis- 
sion on  January  29  she  was  seized  with  bilious  vomiting,  to 
which  she  was  very  liable.  This  lasted  two  days,  when  she 
was  attacked  by  sudden  acute  pain  in  the  right  iliac  region, 
and  from  this  time  she  had  no  motion  of  the  bowels,  with 
the  exception  of  some  scybala  brought  away  by  an  enema, 
till  her  death.  The  vomiting  continued,  and  became  ster- 
coraceous. 

No.  1,595,  from  the  same  patient,  shows  a  portion  of  a 
liver,  with  the  gall-bladder,  stomach,  and  duodenum. 

The  fundus  of  the  gall-bladder  is  adherent  to  the  first  part 
of  the  duodenum,  and  a  fistulous  opening  exists  between 
them,  through  which  a  glass  rod  is  passed. 

The  large  gall-stone  had  escaped  through  the  opening. 

Schuller  (Strasburg,  1891),  in  reviewing  139  published 
cases,  found  that  the  subjects  were  women  in  74*3  per  cent., 
and  out  of  these  75  per  cent,  of  the  cases  occurred  in  women 
over  fifty,  though  instances  were  found  from  eighteen  to 
ninety-four. 

Lobstein,  of  Heidelberg  {Annals  of  Surgery,  January,  1896), 
gives  the  most  common  age  between  forty  and  sixty  ;  Mr. 
Eve  gives  it  as  sixty-four,  and  Sir  Frederick  Treves  as 
fifty-seven. 

It  is  a  curious  fact  that,  although  the  calculi  usually  pro- 
duce intestinal  trouble  within  a  few  days  of  reaching  the 
intestine,  in  some  cases  they  may  remain  in  the  bowel  for 
long  periods — e.g.,  in  a  case  (Transactions  of  Clinical  Society, 
1895)  of  Mr.  Eve's,  ten  years,  and  in  one  (Lancet,  December  3, 
1887)  of  Mr.  Smith's,  probably  fifteen  years. 

Sir  Frederick  Treves,  in  connection  with  this  matter,  says 
that  the  concretions  are  liable  to  grow  by  deposition  of  salts 
and  faecal  matter  during  their  stay  in  the  intestine. 

In  Courvoisier's  elaborate  statistics,  out  of  fifty-three  cases 
examined,  he  gives  the  site  of  obstruction  as  21*4  per  cent. 


154    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

in  the  duodenum  and  jejunum,  65-4  per  cent,  in  the  ileum, 
10  per  cent,  at  the  ileo-caecal  valve,  and  2*4  per  cent,  in  the 
sigmoid  flexure. 

Leichtenstern,  from  an  examination  of  32  cases,  gives  the 
following  result.  In  the  duodenum  and  jejunum,  10  cases ; 
in  the  middle  ileum,  5  cases  ;  in  the  lower  part  of  ileum, 
17  cases. 

Barnard  (loc.  cit.)  arranges  the  cases  quoted  by  Treves  and 
those  collected  by  himself  according  to  the  diameter  of  the 
stone  and  the  point  of  obstruction  : 

Point  of 
Obstruction. 

-  Upper  jejunum. 

-  Jejunum. 

-  Middle  jejunum. 

-  Lower  jejunum. 

-  Five  feet  up  ileum. 

-  Several  feet  up  ileum. 

-  Ileum. 

-  Five  feet  up  ileum. 
1         „                       -             -  Ileo-caecal  valve. 

Museum  specimens  amply  demonstrate  that  the  gall-stones 
producing  obstruction  of  the  intestine  in  nearly  every  case 
enter  the  bowel  through  a  gall-bladder  duodenal  fistula. 
They  rarely  enter  through  the  colon  :  only  two  specimens  of 
the  latter  condition  were  found  in  the  London  museums, 
specimen  No.  S64,  Charing  Cross  Museum,  being  one. 

The  disease  is  a  peculiarly  fatal  one.  Out  of  280  cases 
collected  by  Schuller,  Dufort,  and  Courvoisier,  156  died — 
i.e.,  52  per  cent. 

Kermisson  and  Rochard,*  out  of  105  collected  cases,  gave 
the  mortality  as  50  per  cent. 

The  cases  that  recovered  lasted  on  the  average  8  days, 
those  that  died  10  days,  but  the  duration  of  obstruction 
may  vary  from  1  to  28  days. 

Lobstein  collected  92  cases.     Of  the  61  not  operated  on, 
32  recovered,  the  remaining  29  died  of  peritonitis,  or  exhaus- 
tion ;  of  the  31  operated  on,  12  recovered;  but,  as  many  of 
*  Archills  Gt'm'ralcs  de  Mcdccinc,  February,  1892. 


Diameter  of 

Calculus. 

2i 

inches 

il 

55 

ii 

5J 

it 

55 

4 

)> 

1 

inch 

1 

j» 

7 

8 

>j 

INTESTINAL  OBSTRUCTION  i  55 

the   ig  which  died  were  moribund  when   operated  on,  their 
death  cannot  be  charged  to  operation. 

Courvoisier  collected  125  operations  with  a  mortality  of  44  p.  c. 
Schuller               ,,  82  ,,  ,,  ,,  ,,    56    ,, 

Eve  ,,  28  ,,  „  ,,  „    40    ,, 

H.L.Barnard  ,,  8  ,,  ,,  ,,  ,,    57    ,, 

A  case  reported  by  Dr.  Sargent  in  the  British  Medical 
Journal,  1879,  apparently  died  from  the  intensity  of  the  pain, 
after  symptoms  lasting  only  half  an  hour. 

As  more  than  one  large  concretion  may  be  present  in  the 
gut  at  the  same  time,  the  symptoms  of  obstruction  may 
recur  once,  twice,  or  three  times  after  the  first  concretion 
has  been  parted  with. 

Dr.  Maclagan  (Transactions  of  Clinical  Society,  vol.  xxi., 
p.  87)  has  described  two  cases  of  this  kind,  and  Mr.  Clutton 
(ibid.,  p.  79)  has  described  another,  in  which  he  operated 
successfully  within  twenty-four  hours  of  the  onset  of  the 
second  seizure,  and  manipulated  the  stone  through  the  ileo- 
cecal valve. 

Symptoms. — The  symptoms  are  those  of  acute  intestinal 
obstruction  from  other  causes,  with  early  faecal  vomiting  and 
severe  abdominal  pain.  Though  the  onset  is  sudden,  the 
pain  and  collapse  are  frequently  not  severe  until  later  in  the 
attack,  and  the  constipation  may  not  be  well  marked,  flatus 
and  even  faeces  passing  after  the  onset  of  acute  symptoms. 

Vomiting  is  always  a  marked  symptom,  and  bile  may  be 
vomited  in  great  quantity,  as  in  a  case  of  Dr.  Pye-Smith's, 
quoted  by  Sir  Frederick  Treves,  in  which  the  patient  vomited 
10  pints  of  bile  in  forty-eight  hours,  and  died  on  the  sixth 
day  from  a  gall-stone  impacted  in  the  jejunum.  The  higher 
in  the  gut  the  impaction,  the  more  violent,  as  a  rule,  will  be 
the  symptoms  and  the  less  marked  will  be  the  distension. 
The  obstruction  can  only  very  rarely  be  felt  through  the 
abdominal  walls. 

Although  it  is  sometimes  possible,  as  in  Case  99,  to  make 
a  probable  diagnosis  from  the  history  of  previous  gall-stone 
attacks  extending  over  several  years,  yet  in  many  cases  there 
is  absolutely  no  previous  history  to  guide  one,  and  it  is  quite 


156    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

impossible  to  say  whether  or  not  the  attack  is  one  dependent 
on  the  cause  in  question,  or  on  a  volvulus  or  band,  or  internal 
hernia,  which,  if  left,  must  inevitably  lead  to  death,  and  that 
speedily.  The  age  and  sex,  together  with  the  history  of 
chronic  dyspepsia  and  pain  in  the  hepatic  region,  are,  how- 
ever, well  worth  bearing  in  mind,  as  well  as  the  early  and 
persistent  vomiting  and  visible  peristalsis,  limited  to  the 
small  intestines. 

Treatment. — If  the  diagnosis  could  always  be  made  with 
certainty,  this  is  a  condition  in  which  medical  and  expectant 
treatment  might  be  fairly  given  a  trial,  since  we  have  ample 
evidence  of  large  gall-stones  having  safely  passed  without 
other  treatment. 

But  we  must  not  forget  that  52  per  cent,  of  cases  treated 
on  medical  and  expectant  lines  are  fatal,  and  although 
surgery  has  not  yet  shown  a  much  greater  percentage  of 
recoveries,  it  is  because  surgical  means  are  frequently  only 
resorted  to  when  the  case  is  hopeless,  and  after  all  other 
means  have  been  tried. 

When  it  is  borne  in  mind  that  there  are  no  symptoms 
peculiar  to  this  form  of  obstruction,  and  that  the  course 
pursued  by  an  obstruction  by  a  band  or  by  an  internal 
hernia  may  be  exactly  the  same  as  in  gall-stone  obstruction, 
the  surgeon  who  waits  beyond  the  period  when  an  operation 
may  be  undertaken  with  every  hope  of  success  is  incurring  a 
very  serious  responsibility. 

Under  the  heading  of  treatment,  Sir  Frederick  Treves 
says :  As  soon  as  symptoms  of  obstruction  are  pronounced, 
laparotomy  should  be  performed.  He  advocates  preliminary 
lavage  of  the  stomach,  and  after  removal  of  the  stone 
he  advises  emptying  the  intestine  above,  and  subsequent 
suture. 

With  regard  to  the  method  of  treatment  after  the  abdomen 
is  opened  and  the  cause  found :  if  the  gall-stone  can  be 
easily  crushed  through  the  intestinal  coats,  without  too 
much  force  being  required,  it  may  possibly  be  justifiable, 
though  it  should  be  borne  in  mind  that  the  bowel  may  be 
ulcerated  and  softened  at  the  place  of  impaction,  and  that 
even    the    slight    force    required  to  crush   a   soft  stone    may 


INTESTINAL  OBSTRUCTION  157 

produce  so  much  additional  damage  as  to  lead  to  gangrene 
and  subsequent  perforation.  On  the  whole,  therefore,  I 
would  urge  enterotomy,  either  at  or  above  the  seat  of 
impaction,  and  removal  of  the  stone,  as  it  can  be  done  very 
quickly  and  with  very  little  damage  to  the  bowel. 

Should  the  patient  be  too  ill  to  bear  a  search  being  made 
for  the  obstruction,  enterostomy,  or  perhaps  short-circuiting, 
might  be  performed,  in  order  to  give  temporary  relief,  the 
cause  of  the  obstruction  being  afterwards  removed,  if  this 
be  not  effected  naturally. 

As  to  when  operation  should  be  done,  that  is  part  of  a 
general  question  which  each  surgeon  will  have  to  answer  for 
himself  in  every  individual  case,  as  no  definite  rule  can 
possibly  be  formulated  which  will  apply  to  all  cases.  The 
surgeon  will,  as  a  rule,  not  be  called  in  before  decided 
symptoms  of  intestinal  obstruction  have  manifested  them- 
selves, and  until  medical  means  have  been  fully  tried.  In 
such  cases  it  would  seem  to  me  to  be  idle  waste  of  time  to 
delay  surgical  intervention  until  the  patient  is  so  exhausted 
that  operation  is  only  undertaken  as  a  dernier  ressort,  when 
the  subject  is  almost  moribund.  If,  however,  the  case  be 
seen  at  an  earlier  stage,  morphia  will  have  to  be  given  to 
relieve  the  pain,  and  it  will  be  well  to  recommend  ext. 
belladonnas  in  ]-grain  doses  every  four  hours,  the  stoppage 
of  all  feeding  by  the  mouth,  and  the  administration  of 
one  or  more  large  siphon  enemas,  given  slowly  with  the 
buttocks  elevated.  If  relief  does  not  speedily  follow,  and 
the  diagnosis  is  not  clear,  chloroform  anaesthesia  may  assist 
in  two  ways :  in  the  first  place,  it  enables  a  thorough 
examination  of  the  abdomen,  and  at  times  a  diagnosis  of 
the  cause,  to  be  made;  and,  secondly,  the  manipulation,  if 
made  methodically,  may  reduce  a  hernia  or  volvulus,  or  may 
possibly  help  onwards  an  obstruction.  This  failing,  and  the 
symptoms  persisting,  resort  to  operation  should  not  be  de- 
layed, and  at  this  comparatively  early  stage  there  will  be 
every  prospect  of  success. 

The  second  variety,  volvulus  of  the  small  intestine,  dependent 
on  the  violence  of  the  colic  caused  by  an  attack  of  gall- 
stones, or  on   the  contortions   induced  by  the  passage  of  a 


158    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 
large   concretion    through    the    small  intestine,    is  probably 


uncommon. 


The  following  are  abbreviated  notes  of  two  cases  under  my 
own  care. 

Case  i. — Acute  intestinal  obstruction  in  a  woman  of  sixty- 
eight ;  operated  on  November  12,  1890,  by  laparotomy,  on 
the  eighth  day  of  the  obstruction,  a  volvulus  of  the  small 

intestine  being  discovered 
and  untwisted.  Bowels 
moved  by  enema  on  the 
sixteenth  day  after  onset  of 
obstruction,  and  eighth  day 
after  operation,  and  a  large 
gall-stone,  3  inches  in  cir- 
cumference and  if  inches 
Fig.  41. -Drawing  of  Gall-stone,      ,  passed,  this  being 

ACTUAL    SIZE,    FROM    CASE    30.  °>  ~"    ¥  >  t> 

manifestly  the  cause  of  the 
obstruction,  and  secondarily  of  the  volvulus.  The  patient 
returned  home  on  the  twenty-sixth  day,  and  remained  quite 
well  when  heard  of  a  year  subsequently.  (Case  No.  30. 
Fig.  41.) 

Case  2. — Mrs.  O.,  aged  sixty-two,  was  found  to  be  suffer- 
ing from  acute  obstruction  of  six,  and  faecal  vomiting  of  two, 
days'  duration,  the  onset  having  started  like  a  gall-stone 
attack,  with  pain  over  the  gall-bladder,  and  later  in  the 
umbilical  region.  She  gave  a  history  of  having  suffered 
from  attacks  of  gall-stones  for  several  years,  some  of  which 
had  been  followed  by  jaundice  ;  and  from  the  mode  of  onset 
of  the  present  seizure,  and  the  slight  jaundice  following  it, 
she  was  quite  sure  the  attack  had  been  one  of  her  old 
seizures  at  the  commencement.  From  the  persistence  of  the 
faecal  vomiting,  the  presence  of  visible  intestinal  peristalsis, 
and  the  pinched  and  anxious  countenance,  with  the  absence 
of  relief  by  ordinary  medical  means,  operation  was  decided 
upon.  Laparotomy  was  performed,  and  volvulus  of  the  small 
intestine  being  found,  the  loop  of  gut,  which  was  much  con- 
gested, was  untwisted,  and  the  abdomen  closed.  Flatus 
passed  the  same  day,  and  the  bowels  were  opened  the  next. 
The  wound  healed  by  first  intention,  and  recovery  was  un- 
interrupted.    (Case  No.  88.) 


INTESTINAL  OBSTRUCTION  159 

Diagnosis. — In  this  class  of  cases  (volvulus)  a  positive 
diagnosis  is  probably,  for  the  most  part,  out  of  the  question,, 
except  after  the  abdomen  is  opened,  as  volvulus  of  the  small 
intestine  is  an  extremely  rare  event,  and  we  know  that  a  large 
gall-stone  may  quietly  ulcerate  its  way  into  the  gut  without 
any  preliminary  warning,  the  symptoms  only  arising  when 
the  concretion  is  passing  through  the  small  bowel ;  but  in 
both  cases  related,  in  addition  to  the  signs  of  acute  obstruc- 
tion, there  was  a  well-marked  localized  swelling  near  the 
umbilicus,  becoming  hard  during  the  paroxysms,  pointing  to 
the  site  of  the  obstruction  ;  and  in  the  second  case  there 
was  not  only  the  previous  history  of  cholelithiasis,  but  the 
characteristic  onset  of  a  gall-stone  attack,  followed  by  acute 
symptoms. 

Treatment. — In  this  form,  operation  holds  out  the  only  hope 
of  success,  as,  the  obstruction  being  mechanical,  nothing 
short  of  remedying  the  cause  can  be  of  use. 

The  third  class  is  characterized  by  obstruction  coming  on 
after  the  original  cause  has  disappeared,  and  depends  on 
adhesions  left  by  local  peritonitis  due  to  gall-stone  attacks  ; 
or  on  narrowing,  caused  by  the  healing  of  a  fistula  through 
which  a  gall-stone  has  made  its  way  into  the  intestinal  tract  ; 
or  on  chronic  inflammation  and  ulceration  of  the  bowel  set 
up  by  the  presence  of  a  gall-stone. 

A  good  example  is  afforded  by  Case  160,  where  ad- 
hesions of  the  colon  to  the  gall-bladder  led  to  constipation 
and  attacks  of  partial  obstruction,  which  were  entirely  cured 
by  an  operation  in  which  the  adhesions  were  separated. 

In  Case  199,  though  there  were  no  gall-stones,  an  attack 
of  typhoidal  cholecystitis  produced  adhesions  involving  the 
colon,  and  led  to  the  formation  of  a  band  which  compressed 
the  bowel  and  caused  obstruction.  The  patient,  Mrs.  L.  S., 
aged  thirty-six,  was  admitted  to  the  Leeds  Infirmary  with 
intestinal  obstruction  of  a  week's  duration,  which  was  re- 
lieved by  ^-grain  doses  of  extract  of  belladonna  and  the  use 
of  enemata.  Six  months  before  this  seizure  she  had  a  severe 
attack  of  typhoid  fever,  which  was  followed  by  steadily 
increasing  constipation  and  the  discharge  of  small  motions, 
accompanied  by  a  little  blood  and  mucus.     The  patient,  being 


160    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

so  much  better  under  medical  treatment,  was  discharged,  but 
had  to  be  readmitted  on  account  of  a  return  of  the  obstruc- 
tion, with  which  she  had  been  threatened  on  several  occasions 
during  the  month  she  had  spent  at  home  under  the  care  of 
her  own  medical  man. 

On  admission,  the  abdomen  was  distended,  and  there  was 
distinct  tenderness  in  the  right  hypochondriac  region. 
Though  the  symptoms  were  not  so  acute  as  when  she  was  in 
the  hospital  before,  it  was  decided  to  open  the  abdomen  in 
order  to  discover,  and  if  possible  to  remove,  the  cause  of  the 
obstruction. 

The  operation  was  performed  through  a  median  incision, 
and  the  transverse  colon  was  found  to  be  contracted  along 
its  whole  course,  to  the  size  of  the  middle  finger.  The 
ascending  colon  and  the  small  intestine  were  much  dis- 
tended, and  when  they  were  held  aside  two  bands  were 
found  passing  from  the  gall-bladder  quite  across  the  hepatic 
flexure  of  the  colon,  one  of  them  completely  encircling  it. 
On  division  of  these,  the  cause  of  the  obstruction  was  re- 
moved, and  the  transverse  colon  immediately  became  dis- 
tended. The  abdomen  was  then  closed.  The  bowels  were 
opened  on  the  day  after  operation,  and  before  she  left  the 
hospital  they  were  opened  daily  without  aperients  or  artificial 
help  of  any  kind. 

In  this  case,  the  relation  between  the  fever  and  the  chole- 
cystitis seems  to  be  very  clear,  and  it  was  probably  only 
owing  to  the  ducts  being  free  that  the  more  serious  trouble 
of  phlegmonous  cholecystitis  did  not  supervene  at  the  time 
of  the  attack  of  typhoid,  for  the  inflammation  of  the  gall- 
bladder must  have  been  very  severe  to  have  extended  to  the 
peritoneal  coat,  and  led  to  the  pouring  out  of  so  much  lymph 
as  the  rirm  adhesions  demonstrated. 

Ward  (Pathological  Society's  Transactions,  1852,  p.  357) 
has  placed  upon  record  a  case  of  cicatricial  stricture  of 
the  ileum  which  was,  without  much  doubt,  due  to  the 
ulceration  set  up  by  impacted  and  long-retained  gall- 
stones. 

The  following  case,  which  came  under  my  care,  was  one  of 
thickening  and  ulceration  of  the  bowel  probably  set  up  around 


INTESTINAL  OBSTRUCTION  161 

a  gall-stone,  and  ultimately  leading  to  chronic  tuberculosis 
and  stricture  : 

Miss  H.,  aged  fifty-one,  seen  with  Dr.  Fetch,  of  York. 

Family  history  on  father's  side  negative,  on  mother's  side 
decidedly  tuberculous. 

Previous  History. — She  appeared  to  overgrow  her  strength 
between  the  ages  often  and  fourteen  years.  When  ten  years 
old  she  had  a  glandular  swelling  in  the  neck,  which  was  in- 
cised. No  cough  until  twelve  or  thirteen  years  ago,  since 
which  time  she  has  been  troubled  by  bronchial  catarrh  every 
winter.  No  perspiration  at  night.  Has  recently  lost  flesh 
and  strength  very  considerably.  For  some  fifteen  or  twenty 
years  the  patient  has  suffered  from  so-called  '  bilious ' 
attacks,  accompanied  by  vomiting  and  pain  across  the 
abdomen,  which  would  pass  away  after  a  few  hours  with 
diarrhoea.  She  had  a  bad  colour  at  the  time  of  the  attacks, 
but  had  no  apparent  jaundice. 

These  attacks  had  occurred  for  some  years,  with  perhaps  a 
month's  interval  between  each.  Five  years  ago  the  character 
of  the  attacks  appeared  to  gradually  change,  and  three  years 
ago  their  place  was  taken  by  a  constant  pain  across  the  waist 
and  back.  The  pain  did  not  radiate,  and  was  accompanied 
by  indigestion  and  flatulence.  She  was  subject  to  attacks  of 
constipation  for  two  or  three  days,  followed  by  three  or  four 
days'  diarrhoea,  which  would  be  accompanied  by  griping 
pain  and  would  come  on  quite  suddenly  and  unexpectedly. 
No  distension  noted,  no  tenderness  during  intervals  of  pain, 
no  tenesmus,  stools  as  a  rule  watery,  slight  bleeding  from 
the  bowel  on  defalcation  five  or  six  years  ago,  but  no  blood 
noticed  since. 

When  seen  by  me  on  July  22,  the  patient  was  very  thin, 
and  it  was  easy  to  see  vermicular  contraction  of  the  intes- 
tines, the  tumour  coming  and  going  at  varying  intervals,  the 
pain  being  at  times  very  severe.  On  examining  by  the 
rectum,  a  nodular  growth  could  be  felt  in  Douglas's  pouch, 
which  was  quite  movable  from  side  to  side,  and  could  be 
pushed  out  of  reach. 

Operation  was  advised,  and  was  performed  in  York  on 
July  26. 


162    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

The  abdomen  was  opened  in  the  middle  line,  and  the 
tumour  previously  felt  by  the  rectum  was  discovered  to  be  a 
coil  of  intestine,  very  much  thickened  and  forming  a  mass  as 
shown  in  the  photograph,  there  being  no  less  than  four  dis- 
tinct strictures,  the  first  within  ij  feet  of  the  last,  and 
all  in  the  ileum.  The  affected  area  was  brought  through  the 
incision,  surrounded  by  sterilized  gauze,  and  excised,  the 
healthy  bowel  being  sutured  end  to  end  over  a  decalcified 
bone  bobbin. 

I  have  not  seen  the  patient  since,  but  have  heard  that  she 
recovered  from  her  operation  and  gained  flesh  and  strength, 
and  is  now  well  and  strong. 

The  specimen  removed  was  examined  by  Dr.  Norman 
Smith,  pathologist  to  the  Leeds  Infirmary,  who  gave  the 
following  report  (Fig.  42). 

'  There  is  a  great  increase  of  small  round  leucocytes  and 
of  connective  tissue  in  the  submucous  layer.  At  places  the 
leucocytes  form  dense,  deeply  stained  aggregations.  Seen 
by  the  higher  powers,  they  are  made  up  of  a  peripheral  part 
composed  of  small  cells,  and  a  central  portion  of  large  cells. 
They  are  apparently  giant-cell  arrangements.  At  places  in 
the  muscular  coat  the  same  arrangement  is  commencing  to 
be  formed.  At  one  point  in  the  lumen  of  the  bowel  is  seen 
a  gall-stone  imprisoned  between  two  of  the  strictures.  The 
question  arises  as  to  whether  the  irritation  caused  by  the 
gall-stone  may  have  initiated  the  tubercular  disease.' 

The  specimen  is  an  extremely  interesting  one,  as  showing 
how  near  to  stenosis  it  is  possible  to  get  without  complete 
obstruction  ;  it  shows  a  gall-stone  entangled  in  a  pouch 
between  two  of  the  strictures  at  the  point  marked  X. 

Dr.  Brockbank  refers  to  a  case  reported  in  the  Transac- 
tions of  the  Pathological  Society  of  London,  1852,  in  which 
there  was  chronic  inflammation  and  thickening  of  the  ileum 
and  caecum,  with  destruction  of  the  ileo-caecal  valve,  these 
being  dependent  on  gall-stones  found  in  the  thickened  and 
ulcerated  bowel.  The  bowel  was  dilated  above  the  obstruc- 
tion and  much  contracted  below. 

The  patient  suffered  from  chronic  diarrhoea  for  three  years, 
which  alternated  with  attacks  of  obstruction. 


PLATE  XVIII. 


Fig.  42. — Gall-stone   in   Lumen   of    Bowel   between    Two   Strictures 
due  to  Chronic  Tuberculosis. 

(Specimen  in  Pathological  Museum  of  Leeds  Medical  School.) 


To  face  p.  162.] 


INTESTINAL  OBSTRUCTION  163 

In  the  fourth  variety  the  symptoms  may  be  so  severe  as  to 
resemble  strangulation  by  a  band  or  acute  intussusception. 
The  diagnosis  will  not,  as  a  rule,  be  difficult,  as  the  history 
of  the  occurrence  of  previous  attacks  of  spasms,  though  not 
of  necessity  followed  by  jaundice,  the  similarity  to  these  of 
the  commencement  of  the  attack  in  question,  the  severe 
and  persistent  pain,  at  first  localized  to  the  right  side  of  the 
abdomen,  the  absence  of  distension  at  the  commencement, 
and  then  the  occurrence  of  distension  on  the  right  side  only, 
becoming  general  later,  the  lateness  of  the  onset  of  faecal 
vomiting,  and  only  after  continued  retching,  the  existence  of 
collapse  at  an  early  stage  owing  to  the  severity  of  the  pain, 
which  is  usually  relieved  by  a  morphia  injection,  the  usual 
absence  of  visible  peristalsis,  and,  lastly,  the  onset  of  jaun- 
dice, if  the  concretions  have  reached  the  common  duct, 
afford  so  much  guidance  that  error  will  not  often  occur, 
especially  if  the  patient  be  a  woman  of  middle  or  old  age. 
But  that  difficulties  may  arise  is  shown  by  the  cases  about 
to  be  mentioned. 

Many  cases  of  this  kind  are  seen,  but  it  will  be  necessary 
here  only  to  mention  three,  as  showing  the  difficulty  in 
diagnosis  and  the  extreme  urgency  of  the  symptoms. 

Case  i. — The  patient,  Mrs.  ,  aged  sixty,  was  sent  by 

her  medical  adviser,  Dr.  H.,  into  a  surgical  home  in  Leeds 
for  immediate  operation  for  acute  intestinal  obstruction, 
faecal  vomiting  having  been  present  for  three  days,  and 
medical  treatment  having  failed  to  give  relief. 

On  arrival,  she  was  too  exhausted  and  ill  to  bear  operation, 
and  morphia  was  administered  to  relieve  her  distress  and 
combat  the  collapse  due  to  the  intense  pain. 

Rectal  feeding  was  at  once  begun  in  order  to  maintain  the 
strength,  and  ext.  bellad.  was  given  every  four  hours  in 
J-grain  doses.  The  patient  forthwith  began  to  improve,  and 
a  clear  history  of  cholelithiasis  was  obtained,  this  attack,  the 
patient  said,  differing  in  no  respect,  except  in  severity,  from 
those  she  had  frequently  had  on  former  occasions.  There 
was  marked  tenderness  over  the  gall-bladder,  particularly  at 
a  point  one-third  of  the  distance  in  a  straight  line  between 
the  ninth  costal  cartilage  and  the  umbilicus,  together  with 

11 — 2 


1 64    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

some  swelling  in  the  right  hypochondrium,  slight  tympanitic 
distension  of  the  abdomen  generally,  some  jaundice,  and  the 
history  of  a  sudden  onset  followed  by  two  or  three  slight 
ague-like  attacks.  Flatus  passed  the  night  of  admission, 
and  continued  to  pass  at  intervals. 

After  two  days  the  bowels  were  freely  relieved  after  a  large 
enema  had  been  administered.  No  large  gall-stone  was  dis- 
covered, but  several  small  concretions,  which  had  evidently 
passed  through  the  common  duct,  were  found.  She  returned 
home  in  the  third  week,  and  has  remained  well. 

Case  2. — Mrs.  R.,  aged  fifty-six,  was  admitted  on  July  18, 
1893,  into  the  Leeds  Infirmary,  with  symptoms  of  acute 
intestinal  obstruction  of  three  days'  and  faecal  vomiting  of 
twenty-four  hours'  duration.  The  patient  was  jaundiced 
and  was  in  very  great  pain,  the  pain  having  begun  over  the 
gall-bladder,  radiating  thence  over  the  abdomen,  and  through 
to  the  right  scapular  region.  She  gave  the  history  of  having 
had  numerous  gall-stone  attacks  during  the  previous  fifteen 
years,  but  she  had  never  been  so  severely  affected  as  on  the 
present  occasion. 

A  morphia  injection,  followed  by  J-grain  doses  of  ext. 
bellad.  every  four  hours,  and  rectal  feeding,  soon  gave  relief 
to  the  urgent  symptoms,  and  the  bowels  were  moved  on 
the  third  day,  after  which  recovery  was  uninterrupted.  On 
October  21,  1893,  the  patient  having  completely  recovered 
from  the  obstruction,  but  the  spasmodic  pain  followed  by 
jaundice  having  recurred,  the  abdomen  was  opened,  and 
numerous  adhesions  of  the  colon  and  duodenum  to  the  gall- 
bladder and  bile-ducts  were  found. 

Cholecystotomy  was  performed,  and  six  stones  were  re- 
moved, others  in  the  common  duct  being  crushed  between 
the  finger  and  thumb. 

The  patient  was  discharged  cured  in  a  month,  and  has 
been  well  since  (Case  78). 

Case  3. — A  woman,  aged  forty-seven,  was  admitted  into  the 
Devon  and  Exeter  Hospital  on  May  16,  1895,  under  the  care  of 
Mr.  A.  C.  Roper.*     She  had  had  no  previous  serious  illness 

*  Lancet,  August  22,  1896. 


INTESTINAL  OBSTRUCTION  165 

or  similar  attack.  The  patient  had  been  suffering  great  pain 
in  her  abdomen,  accompanied  by  vomiting,  for  three  days, 
and  had  taken  various  aperients,  resulting  in  one  action  of 
the  bowels  the  previous  morning,  which,  however,  did  not 
give  her  any  relief.  An  enema  of  7  pints  administered  on 
the  night  preceding  her  admission  to  hospital  was  returned 
unstained.  Her  temperature  was  99°  F.,  and  the  pulse  100. 
She  vomited  bile  and  mucus. 

Examination  of  the  abdomen  showed  a  visible  swelling, 
freely  movable,  somewhat  tender,  elastic,  and  distinctly 
resonant  to  percussion,  situated  on  the  right  side  of  the 
abdomen,  extending  from  just  below  and  2  inches  to  the 
right  of  the  umbilicus  up  to  the  margin  of  the  ninth  costal 
cartilage,  from  which  point  resistance  extended  across  the 
abdomen  along  the  line  of  the  transverse  colon.  The  swell- 
ing appeared  to  be  like  a  sausage  in  shape.  A  diagnosis  of 
intussusception  was  arrived  at,  and  under  chloroform  Mr. 
Roper  made  an  incision  in  the  middle  line.  On  opening  the 
peritoneum  he  found  a  red,  inflamed,  sausage-shaped  tumour, 
which  proved  to  be  the  gall-bladder  greatly  distended  and 
elongated,  and  adherent  on  its  posterior  surface  to  the  intes- 
tines. Excepting  collapse  of  the  large  bowel  on  the  distal 
side  of  the  tumour,  nothing  abnormal  was  discovered  in  the 
intestines.  The  gall-bladder  was  very  tense,  and  no  stones 
could  be  found  in  it.  It  was  stitched  to  the  wound  and 
drained.  A  number  of  gall-stones  were  removed  seven  weeks 
later,  and  the  patient  made  a  good  recovery. 

Mr.  Lane's  case,  described  under  Phlegmonous  Chole- 
cystitis, is  a  good  example  of  this  form  of  obstruction  from 
inflammation  starting  in  the  gall-bladder  region,  though  in 
his  case  no  gall-stones  were  discovered  at  the  time  of  opera- 
tion. 

These  cases  will,  as  a  rule,  yield  to  general  and  medical 
treatment,  and  it  will  only  occasionally  be  necessary,  as  in 
Mr.  Roper's  and  Mr.  Lane's  cases,  to  resort  to  operation 
during  the  seizure  if  the  symptoms  are  not  subsiding,  though 
subsequent  surgical  treatment  may  be  required. 


CHAPTER  VI 

TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

If  by  tumours  be  understood  new  growths,  then  tumours  of 
the  gall-bladder  and  bile-ducts  are  not  common  ;  but  if  we 
accept  the  usual  interpretation  of  the  term,  and  include  all 
enlargements  as  tumours,  we  shall  find  them  by  no  means 
rare. 

The  subject  will  be  considered  under  the  following  classi- 
fication, which  appears  to  include  all  the  chief  varieties  : 

I.  TUMOURS  OF  THE  GALL-BLADDER. 

(A)  Distension  of  the  gall-bladder. 

(a)  Distension  with  bile. 

(b)  ,,  „         concretions. 

(c)  ,,  ,,         pus  (empyema). 

(d)  ,,  ,,  mucus  (hydrops). 

(e)  ,,  ,,  hydatid  cysts. 

(B)  Hypertrophy  and  thickening  of  walls  of  the  gall- 

bladder forming  a   large,  easily   perceptible 
tumour. 

(C)  New  growths. 

(a)  Simple. 

(b)  Malignant. 

II.  TUMOURS  OF  THE  BILE-DUCTS. 

(A)  Distension. 

(B)  New  growths. 

[   166  ] 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS    167 

I.  TUMOURS  OF  THE  GALL-BLADDER. 

Distension  of  the  Gall-bladder. 

A  mere  fulness  of  the  gall-bladder  does  not  necessarily 
form  a  tumour  ;  hence  in  the  absence  of  obstruction  a  gall- 
bladder may  be  larger  than  normal  and  full  of  bile,  yet 
incapable  of  being  felt  through  the  abdominal  wall. 

A  tumour  is  felt  as  soon  as  retention  occurs  under  tension, 
when  the  cyst  full  of  fluid  often  gives  the  sensation  on 
palpation  of  a  pyriform  solid,  it  being  so  hard. 

A  tumour  of  the  gall-bladder  through  distension  with  bile 
is  not  common,  though  it  is  sometimes  described  as  an 
accompaniment  of  a  gall-stone  attack,  where  the  concretion 
is  impacted  in  the  common  duct ;  even  in  such  a  case  it  is 
usually  a  symptom  of  short  duration,  since,  if  the  impaction 
be  complete,  the  bile  speedily  becomes  absorbed,  and  gives 
place  to  distension  by  mucus. 

A  perceptible  tumour  formed  by  distension  with  gall- 
stones is  also  rare,  unless  it  happens  that  some  have  become 
impacted  in  the  cystic  duct,  when  a  gradual  enlargement 
from  the  retained  mucus  will  follow.  As  many  as  720  gall- 
stones were  removed  from  the  gall-bladder  in  Case  107,  and 
yet  that  gall-bladder  could  not  be  felt  as  a  distinct  tumour. 
Occasionally  a  large  single  stone  may  form  a  hard,  perceptible 
swelling  below  the  liver,  as  in  the  following  case. 

Case  221. — The  patient,  a  woman,  aged  thirty,  had 
suffered  for  four  years  from  a  constant  pain  in  the  right 
hypochondrium  of  a  dull,  aching  character,  considerably 
worse  on  exertion,  and  occasionally  radiating  into  the  right 
subscapular  region.  During  the  attacks  she  vomited,  but 
never  had  a  rigor,  and  was  never  jaundiced.  On  abdominal 
examination,  a  hard,  globular,  tender  mass  was  felt  below 
the  right  costal  margin,  which  was  freely  movable  from  side 
to  side,  and  moved  with  respiration. 

Operation,  July  7,  1898. — A  large  oval  stone,  which  was 
the  tumour  felt  before  the  operation,  was  extracted  from  the 
gall-bladder.      It    measured  2]  by  if  inches,  and   weighed 


i68    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

I  ounce  30  grains.  The  gall-bladder  was  drained  for  four 
days,  and  the  patient  made  a  perfect  recovery. 

Fig.  43,  a  photograph  of  a  specimen  in  the  Hunterian 
Museum,  is  also  an  example. 

Calcified  gall-bladder,  which  is  due  to  cholelithic  catarrh, 
may  lead  to  the  formation  of  a  hard,  rounded,  painless 
tumour;  and  this  is  evidently  not  uncommon,  if  we  may 
judge  of  its  frequency  by  specimens  in  the  museums. 

Specimens  No.  2,808  and  2,8o8a  (Fig.  44)  in  the  Royal 
College  of  Surgeons  Museum  are  good  examples,  as  also 
are  No.  1,402  in  Guy's  and  No.  1,599  m  tne  Middlesex 
Museums. 

The  specimen  from  the  Middlesex  Museum  is  interesting 
in  that  it  was  removed  from  a  woman  of  nearly  seventy,  and 
contained  bile  and  one  concretion. 

A  specimen  of  my  own  is  in  the  Leeds  Pathological 
Museum  ;  the  history  is  as  follows : 

Case  375. — Choledochotomy  and  Cholecystectomy — Recovery. 
— Mrs.  W.,  aged  fifty-seven,  seen  with  Dr.  M.,  of  Bolton, 
for  repeated  attacks  of  biliary  colic  associated  with  jaundice 
of  three  weeks'  standing  and  rapid  loss  of  flesh. 

Operation,  June  8,  1901,  when  a  gall-stone  was  found  in 
the  common  duct,  and  one  in  a  calcareous  gall-bladder,  the 
shape  and  size  of  a  hen's  egg.  Choledochotomy  and 
cholecystectomy  were  performed,  and  followed  by  a  smooth 
recovery,  the  patient  being  quite  well  in  September,  1901. 

Hydrops  and  dropsy  of  the  gall-bladder  are  terms  used  to 
denote  distension  of  the  gall-bladder  by  mucus.  It  may 
result  from  any  obstruction  in  the  cystic  or  common  ducts, 
whether  due  to  gall-stones,  stricture,  or  growth  in  the  ducts, 
or  to  cancer  of  the  head  of  the  pancreas,  provided  that  the 
gall-bladder  has  not  atrophied  as  the  result  of  previous  gall- 
stone irritation.  It  is  due  to  the  gradual  accumulation  of 
the  natural  secretion  of  the  mucous  lining,  and  may  attain 
such  a  size  as  to  be  mistaken  for  an  ovarian  cyst,  as  in  cases 
reported  by  Lawson  Tait,  Mayo,  and  Kocher,  though  it  is 
uncommon  to  find  the  tumour  of  greater  size  than  15  to 
20  ounces'  capacity.  In  the  St.  Bartholomew's  Museum  is 
a  specimen  in  which  the  lower  end  of  an  enormously  dilated 


PLATE  XIX. 


Fig.  43. — Large   Single    Calculus  filling 
the  Gall-bladder. 

(No.  2,819,  Hunterian  Museum.) 


Fig.    44. — -Calcification    of    Gall-bladder. 
(No.  2,8o8a,  Royal  College  of  Surgeons  Museum. 


To  face  p.  168.  ] 


PLATE  XX. 


Fig.  45. — Distended    Gall-bladder    and    Pouch    at   Fundus  caused    by 
Calculus  obstructing  Cystic  Duct. 
(No.  2,814,  Royal  College  of  Surgeons  Museum.) 


V 


Fig.   46. — Hypertrophy    and   Dilatation 
of  Gall-bladder,  with  Pouches  formed 
by    the    Mucous     Membrane    bulging 
between  the  Muscular  Fasciculi. 
(No.  2,804,  Royal  College  of  Surgeons 
Museum.) 

To  face  />  iq6.1 


47. — Contracted    Gall- 
bladder,     with       Hyper- 
trophy of  Walls   due   to 
Gall-stone  Irritation. 
(No.  2,807,   Royal  College   of 
Surgeons  Museum.) 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE -DUCTS    169 

gall-bladder  had  passed  through  the  right  femoral  ring,  form- 
ing the  contents  of  the  sac  of  a  femoral  hernia,  and  which 
was  first  discovered  at  the  operation. 

Specimen  No.  1,416,  Guy's  Museum,  shows  a  distended 
gall-bladder  containing  colourless  mucus,  and  at  the  post- 
mortem no  obstruction  was  found  in  the  ducts.  The  patient 
died  from  pyaemia  after  acute  necrosis  of  bone. 

Specimen  No.  1,587,  Middlesex  Museum,  shows  an 
enormously  dilated  gall-bladder,  the  result  of  impaction  01 
a  gall-stone  at  the  neck  of  the  gall-bladder. 

Specimen  No.  2,814,  Royal  College  of  Surgeons  Museum, 
shows  a  large  gall-bladder  with  a  gall-stone  impacted  in  the 
cystic  duct  (Fig.  45). 

Reymond  {Revue  de  Chirurgie,  June,  1900)  reports  a  case 
of  movable  kidney  with  hydronephrosis,  due  to  compres- 
sion of  the  pedicle  of  the  kidney  by  a  distended  gall- 
bladder. Nephropexy  was  performed,  and  subsequently 
cholecystotomy,  when  a  large  quantity  of  purulent  fluid  and 
four  gall-stones  were  removed  from  the  gall-bladder.  The 
patient  made  a  good  recovery. 

In  the  Appendix  will  be  found  examples  of  distension  of 
the  gall-bladder  due  to  the  following  conditions  : 

1.  Calculus  in  the  cystic  duct. 

2.  Stricture  of  the  cystic  duct. 

3.  Obstruction  of  the  common  duct  from  growth, 

stricture,  and  calculus. 

4.  Chronic  pancreatitis. 

5.  Cancer  of  ampulla  of  Vater. 

6.  Cancer  of  the  head  of  the  pancreas. 

7.  Movable  kidney  and  kinking  of  the  bile-duct. 

Empyema  of  Gall-bladder.— If  the  obstruction  be  associated 
with  inflammation,  the  contents  of  the  gall-bladder  may 
become  purulent,  and  an  empyema  of  the  gall-bladder  may 
result,  the  symptoms  and  complications  of  which  have 
already  been  considered  (see  p  85). 

Hypertrophy  of  the  gall-bladder  forming  a  large  tumour  is 
not  infrequently  seen  as  a  result  of  cholelithiasis.  Figs.  46 
and  47  afford  good  examples ;  in  both  cases  the  walls  of  the 


170    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

gall-bladder  are  much  thickened,  the  cavity  in  one  being 
almost  obliterated  and  in  the  other  dilated  and  pouched. 
The  contents  may  be  mucus  or  muco-pus,  and  gall-stones 
may  or  may  not  be  present  when  the  tumour  is  removed, 
though  probably  in  every  case  biliary  concretions  have 
actually  initiated  the  trouble  by  obstructing  the  outlet  and 
producing  cholecystitis. 

On  two  occasions  I  have  performed  cholecystectomy 
(Cases  234  and  340)  under  the  idea  that  the  tumour  was 
malignant,  though  an  examination  of  the  specimen  subse- 
quently has  shown  the  true  nature  of  the  disease. 

Case  340. — Mrs.  E.  L.,  aged  forty-two,  seen  at  the  Leeds 
General  Infirmary  on  October  1,  1900.  Had  suffered  from 
attacks  of  biliary  colic  for  eighteen  months.  During  the 
last  three  months  the  attacks  had  been  very  severe,  and 
accompanied  by  transient  jaundice.  She  had  lost  2h  stones 
in  weight. 

Operation,  October  10,  1900. — The  gall-bladder  was  found 
adherent  and  full  of  calculi.  Some  friable  tissue,  probably 
growth,  was  found  involving  the  wall  of  the  gall-bladder  and 
liver  in  the  immediate  neighbourhood.  Several  gall-stones 
were  found  in  a  cavity  in  the  liver  substance  which  was 
apparently  due  to  the  necrosis  of  malignant  growth. 

The  liver  was  drawn  out  through  the  abdominal  incision, 
and  two  pins  passed  through  below  the  growth,  one  trans- 
fixing the  cystic  duct.  A  stout  rubber  ligature  was  passed 
round  below  the  pins  and  tied  tightly.  The  solid  portion  of 
liver,  with  the  gall-bladder,  was  then  amputated.  The 
patient  made  a  good  recovery. 

Report  on  the  tissue  removed  says:  Chronic  inflammation, 
possibly  tuberculous.     No  evidence  of  malignant  disease. 

Firm  adhesions  to  the  neighbouring  organs,  the  result  of 
local  peritonitis,  form  a  distinct  feature  of  these  tumours,  and 
though  their  separation  may  be  tedious,  this  should  be  done, 
and  should  be  followed  by  cholecystectomy. 

Lipoma. — As  an  extremely  rare  event,  the  gall-bladder  may 
form  an  adipose  tumour,  as  in  a  specimen  from  Guy's 
Museum,  No.  1,403,  the  walls  of  the  gall-bladder,  infiltrated 
with  fat,  being  J   inch  thick.     It  was  removed  from  a  man 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS    171 

of  sixty-six  suffering  from  kidney  disease  and  cirrhosis  ot 
the  liver. 

Hydatid  of  the  Gall-bladder. — Hydatid  of  the  gall-bladder 
may  occur  primarily,  as  shown  in  the  case  related  below,  but 
it  is  probably  more  common  for  the  disease  to  originate  in 
the  liver,  and  then  to  burst  into  the  gall-bladder,  producing 
symptoms  resembling  gall-stone  seizures. 

The  following  case  is  an  example  of  this  condition  : 

Case  161. — H.  M.,  aged  forty-four,  seen  with  Dr.  Scatterty, 
Keighley.  Patient  had  had  a  tumour  of  the  liver  for  six 
years,  and  for  a  year  had  suffered  from  attacks  resembling 
gall-stone  seizures.  Infective  cholangitis  and  jaundice  were 
present.  It  was  thought  that  the  condition  was  due  to  small 
cysts  discharging  into  the  bile-ducts. 

Operation,  January  28,  1897. — Hepatotomy  with  drainage 
of  cyst.  The  patient  made  a  good  recovery,  the  jaundice 
disappearing,  and  no  recurrence  of  the  attacks  of  pain 
occurring. 

The  following  interesting  case  was  under  the  care  of 
Mr.  Jonathan  Hutchinson,  junr.  : 

A  young  woman,  who  had  never  been  out  of  England,  and 
who,  so  far  as  was  known,  had  had  nothing  specially  to  do 
with  dogs,  developed  symptoms  of  severe  cholecystitis  and 
obstructive  jaundice.  Her  pain  was  as  intense  as  that  met 
with  in  colic  due  to  gall-stones,  and  she  had  repeated  rigors. 
The  distended  gall-bladder  could  be  felt  through  the  ab- 
dominal wall.  At  the  operation  a  large  number  of  hydatid 
cysts,  mixed  with  pus  and  bile,  were  evacuated  from  the 
cavity  of  the  gall-bladder.  It  was  subsequently  ascertained 
that  the  roof  of  the  gall-bladder,  about  midway  between  its 
fundus  and  its  neck,  presented  a  round  aperture  leading  into 
a  hydatid  cyst  in  the  centre  of  the  liver.  Convalescence  was 
very  slow,  as  fragments  of  hydatid  membrane  continued  to 
be  discharged,  and  at  one  time  pleurisy  was  suspected,  but 
without  effusion.  She  gradually  gained  in  strength,  and 
made  ultimately  a  complete  recovery.  The  case  was  under 
Mr.  Roger  Hutchinson  and  Mr.  Jonathan  Hutchinson,  junr. 

Dr.  McGavin  {Lancet,  February  22,  1902)  records  the  fol- 
lowing case : 


172    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

A  woman,  aged  thirty-two,  had  noticed  an  abdominal 
tumour  for  three  years.  About  an  inch  above  the  umbilicus, 
and  slightly  to  the  right  of  the  middle  line,  was  a  hard, 
slightly  lobulated,  roundish  tumour.  It  was  freely  movable, 
especially  to  the  right.  On  percussion  it  was  dull,  and  there 
was  impaired  resonance  between  it  and  the  liver,  which  was 
not  enlarged.  It  was  not  tender  to  ordinary  manipulation. 
The  abdomen  was  opened,  and  the  tumour  found  to  be  the 
gall-bladder  itself,  adherent  to  the  great  omentum.  Chole- 
cystectomy was  performed,  the  patient  making  a  good 
recovery.  The  specimen,  on  examination,  was  found  to  be 
the  gall-bladder,  lined  by  a  thick  hydatid  membrane,  un- 
stained by  bile,  the  cavity  of  the  cyst  being  occupied  by 
numerous  daughter  cysts  and  gelatinous  semi-translucent 
material. 

After  examining  Dr.  McGavin's  specimen,  Mr.  Shattock 
(Pathological  Society  of  London,  October  15,  1901)  was  of 
opinion  that  the  tumour  was  a  pedunculated  hydatid  attached 
to  the  liver,  and  was  not  the  gall-bladder.  The  specimen 
has  been  placed  in  the  Hunterian  Museum  of  the  Royal 
College  of  Surgeons. 

Bowman  (Lancet,  April  8,  1876)  reported  a  case  in  which 
the  patient  died  during  aspiration  of  a  hydatid  cyst  of  the 
lung.  The  gall-bladder  was  found  post-mortem  to  be  dis- 
tended by  a  single  cyst  of  the  size  of  a  foetal  head,  containing 
one  daughter  cyst.  There  had  been  no  jaundice  and  no 
complaint  of  pain  at  any  time. 

Knowsley  Thornton  (Lancet,  April  4,  1891)  reported  a  case 
in  which  the  symptoms  of  acute  biliary  colic  were  followed 
by  jaundice.  Here  the  gall-bladder  contained  a  number  of 
hydatid  cysts  and  much  bile-stained  fluid,  and  one  other  cyst 
was  removed  from  the  omentum. 

Mr.  Page,  of  Newcastle,  described  a  case*  of  hydatid  of 
the  gall-bladder  in  a  man  between  fifty  and  sixty  years  of  age 
who,  until  within  five  years  of  coming  under  Mr.  Page's  care 
in  December,  1897,  na<^  been  in  good  health.  During  that 
period  he  had  suffered  from  occasional  attacks  of  pain  in  the 
epigastric  region,  accompanied  by  vomiting  ;  for  eight  months 

*  Lancet,  April  9,  1898. 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     173 

the  attacks  had  become  more  severe,  and  had  occurred  more 
frequently.  About  October  he  began  to  lose  flesh,  and  the 
pain  and  vomiting  were  almost  continuously  present.  On 
November  24  there  was  first  found  a  tumour  of  some  size, 
connected  with  the  under  surface  of  the  liver,  which  was 
supposed  to  be  a  distended  gall-bladder.  On  December  9, 
1897,  the  abdomen  was  opened  in  the  right  semilunar  line, 
and  the  gall-bladder  exposed.  Some  12  ounces  of  clear, 
colourless  fluid  were  drawn  off  by  aspiration,  and  a  search 
made  for  a  stone  in  the  cystic  duct ;  but  none  was  found. 
The  gall-bladder  was  incised  and  a  collapsed  hydatid  cyst  at 
once  protruded.  This  was  removed,  but  not  in  one  piece. 
No  bile  escaped.  The  margin  of  the  incision  into  the  gall- 
bladder was  then  sutured  to  the  skin,  and  the  abdominal 
wound  closed.  For  eleven  days  the  temperature  continued 
to  be  normal,  and  all  went  well — a  good  deal  of  clear  fluid 
escaping  from  the  gall-bladder  quite  unstained  by  bile.  On 
the  23rd  the  temperature  rose  to  1020  F.,  and  there  was  an 
unpleasant  smell  about  the  dressings.  On  examining  the 
sinus  into  the  gall-bladder,  its  orifice  was  found  to  be  plugged 
firmly  by  a  piece  of  decomposed  hydatid  cyst,  upon  the 
removal  of  which  a  considerable  quantity  of  bile  escaped. 
From  this  time  till  the  middle  of  February  bile  continued  to 
flow,  at  first  so  copiously  that  it  was  necessary  to  change  the 
saturated  dressings  twice,  and  sometimes  three  times  daily. 
Ultimately  the  sinus  closed,  and  the  patient  completely 
regained  health  and  strength. 

'  In  this  case  the  gall-bladder  was  occupied  by  a  single 
hydatid  cyst  containing  no  daughter  cysts.  A  portion  of  the 
cyst  extending  into  the  cystic  duct  had  evidently  not  been 
removed  at  the  time  of  operation.  When  this  retained  portion 
separated  and  became  lodged  in  the  sinus,  bile  flowed  into  and 
distended  the  gall-bladder,  by  this  time  considerably  reduced 
in  size,  escaping  through  the  sinus  as  soon  as  its  plugged 
orifice  was  freed.' 

Actinomycosis  of  the  gall-bladder  is  probably  extremely 
rare,  the  case  described  below,  which  came  under  my  care, 
being  the  only  one  with  which  I  am  acquainted. 

Case  379. — Frank    N.,    aged    forty-seven,    seen    with    Dr. 


174    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Dickey,  Colne.  For  eighteen  months  the  patient  had  been 
losing  flesh,  and  had  suffered  from  pain  in  the  right  hypo- 
chondrium.  For  three  months  the  pain  had  been  very 
acute,  and  he  had  had  severe  attacks  daily.  The  gall-bladder 
was  enlarged  and  tender,  and  there  was  some  dilatation  of 
the  stomach. 

Operation,  July  18,  igoi. — The  gall-bladder  was  found  to 
be  filled  with  soft,  putty-like  debris.  No  gall-stones  were 
found.  The  gall-bladder  was  cleared  out  with  a  scoop,  and 
drained.  The  patient  made  a  good  recovery  from  the 
operation,  and  was  well  and  at  his  work  three  months 
later. 

An  examination  of  the  removed  material  showed  the 
disease  to  be  actinomycosis,  in  consequence  of  which  a 
course  of  iodide  of  potassium  was  prescribed. 

Enlargement  of  the  Gall-bladder.  —  Enlargements  of  the 
gall-bladder  may  vary  from  a  tumour  just  perceptible  to 
the  touch  to  one  of  such  a  size  as  almost  to  fill  the 
abdomen,  though  one  of  greater  size  than  a  large  pear  is 
exceptional.  The  same  tumour  may  also  vary  in  size  at 
different  times,  this  variation  being  frequently  found  in  gall- 
stone obstruction. 

Symptoms. — The  symptoms  of  tumour  of  the  gall-bladder 
depend  for  the  most  part  on  the  cause,  and  in  consequence 
vary  considerably,  at  times  being  slight  and  unimportant,  at 
others  both  urgent  and  serious. 

The  gall-bladder,  as  a  rule,  enlarges  downward  and  for- 
ward in  a  line  which,  drawn  from  the  ninth  or  tenth  costal 
cartilage,  crosses  the  linea  alba  a  little  below  the  umbilicus, 
but  the  position  of  the  tumour  varies  with  the  size  of  the 
liver.  When  that  organ  is  of  normal  size,  the  neck  of  the 
gall-bladder  is  opposite  the  ninth  costal  cartilage,  whereas 
when  the  liver  is  enlarged  the  gall-bladder  will  be  pushed 
down,  so  that  the  neck  of  the  tumour  may  be  opposite  to,  or 
even  below,  the  umbilicus.  If  uncomplicated,  it  will  have 
a  smooth,  rounded,  and  pear-shaped  outline,  the  larger  end 
being  below,  quite  free,  and  movable  from  side  to  side,  the 
upper  end  being  fixed  and  passing  under  the  lower  margin  of 
the  liver  at  the  fissure  of  the  gall-bladder. 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     175 

A  distinct  sulcus  between  the  liver  and  gall-bladder  is 
nearly  always  perceptible  to  the  touch,  if  the  warmed  flat 
hand  be  laid  over  the  right  side  of  the  abdomen,  and  the 
patient  be  told  to  take  a  deep  breath,  when  the  tumour 
and  the  liver  will  descend  together  and  pass  under  the 
fingers. 

Bimanual  palpation  will  frequently  throw  additional  light 
on  the  case,  the  right  hand  being  placed  in  front  of  the 
abdomen,  and  the  left  under  the  right  loin,  making  gentle 
pressure  forwards. 

In  other  cases  additional  information  may  be  obtained  by 
placing  the  patient  in  the  genu-pectoral  position,  and  passing 
the  right  hand  round  the  abdomen  from  behind,  when  a 
tumour  of  the  gall-bladder  wrill  rest  distinctly  on  it,  and  on 
deep  inspiration  the  tumour  can  be  felt  to  move  just  beneath 
the  abdominal  walls,  the  upper  surface  of  the  liver  also  being 
in  this  way  capable  of  palpation. 

The  swelling  is,  as  a  rule,  far  too  tense  and  hard  for 
fluctuation  to  be  elicited,  though  at  times  this  sign  may  be 
obtained  when  the  swelling  is  less  tense. 

In  some  of  the  larger  swellings  a  thrill,  almost  like  the 
hydatid  fremitus,  may  be  felt  on  gently  flicking  the  tumour 
with  the  finger-nail.  Percussion  by  no  means  always  elicits 
dulness  co-extensive  with  the  tumour,  especially  if  the  sur- 
rounding intestines  be  distended ;  so  that  dulness  on  per- 
cussion is  a  very  variable  sign,  and  palpation  will  be  found 
more  reliable. 

Inspection  of  the  abdomen  with  the  patient  recumbent 
will  at  times  show  the  tumour  descending  on  respiration,  but 
this  sign  is  usually  only  to  be  observed  in  thin  patients,  and 
in  cases  uncomplicated  by  inflammation.  When  there  is 
inflammation  and  matting  of  the  adjoining  viscera,  a  fixed 
swelling  may  be  seen  over  the  right  hypochondrium,  with 
dulness  on  percussion  and  marked  tenderness. 

Tenderness  on  palpation  is  a  variable  symptom,  depending 
on  the  presence  or  absence  of  local  peritonitis,  it  being  as 
a  rule  absent  in  uncomplicated  enlargements  of  the  gall- 
bladder. 

Jaundice    may   complicate   tumours   of   the   gall-bladder, 


176    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

both  being  dependent  on  the  same  cause — obstruction  of  the 
common  bile-duct.  Although  not  absolutely  pathognomonic 
of  malignant  disease,  the  combination  should  always  raise 
a  suspicion  of  cancer  of  the  head  of  the  pancreas  or  of  the 
liver  or  bile-ducts,  especially  if  it  be  associated  with  great 
loss  of  flesh  and  strength,  and  with  absence  of  characteristic 
gall-stone  pain. 

We  have  observed,  in  a  considerable  number  of  cases,  dis- 
tension of  the  gall-bladder  with  jaundice  to  be  associated 
with  malignant  disease,  but  much  less  often  the  combination 
of  tumour,  jaundice,  and  gall-stones.  The  explanation  of  this 
apparent  anomaly  is  that  the  gall-bladder  frequently  becomes 
diminished  in  size  and  adherent,  as  the  result  of  gall-stone 
irritation,  so  that  when  the  common  duct  becomes  blocked 
by  a  calculus,  jaundice  occurs  without  distension  of  the  gall- 
bladder, which  is  unable  to  expand. 

If,  however,  the  common  duct  becomes  obstructed  by  gall- 
stones before  the  gall-bladder  has  contracted  and  formed 
adhesions,  there  may  be  the  combination  of  jaundice  and 
tumour. 

If  the  common  duct  be  blocked  by  tumour,  the  gall- 
bladder, not  having  been  subjected  to  irritation,  and 
therefore  not  having  become  contracted,  will  at  once 
distend. 

Thus,  in  malignant  disease  of  the  head  of  the  pancreas  we 
find  the  usual  combination  of  jaundice  with  tumour  of  the 
gall-bladder. 

Gall-bladder  tumours  usually  contain  mucus,  occasionally 
pus,  rarely  bile.  In  all  cases  when  the  cystic  duct  is  ob- 
structed, and  inflammation  has  not  followed,  mucus  alone  is 
present,  though  when  inflammation  co-exists,  pus  or  muco- 
pus  may  be  found. 

In  obstruction  of  the  common  duct  by  gall-stones,  the 
gall-bladder,  though  usually  contracted,  may  be  found  dis- 
tended by  bile  at  first  and  mucus  later  ;  though,  as  a  rule, 
the  swelling  subsides  more  or  less  rapidly  and  no  tumour 
persists,  the  gall-bladder  shrinking.  When  the  obstruction 
becomes  absolute,  as  in  malignant  diseases  of  the  head  of 
the  pancreas,  the  tumour  formed  is  persistent,  and  although 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     177 

the  block  is  in  the  common  duct,  bile  soon  ceases  to  reach 
the  gall-bladder,  and  the  tumour  is  always  found  to  contain 
mucus.  This  occurs  on  account  of  the  backward  pressure 
preventing  the  excretion  of  bile,  which,  though  formed 
by  the  liver  cells,  is  immediately  taken  up  by  the  lym- 
phatics. 

Diagnosis. — Tumours  of  the  gall-bladder  may  have  to  be 
diagnosed  from  : 

1.  Movable  right  kidney. 

2.  Tumour  of  the  right  kidney,  or  of  the  suprarenal 
capsule. 

3.  Tumour  of  intestine  or  faecal  impaction. 

4.  Tumour  of  liver. 

5.  Pyloric  tumour. 

6.  Abnormal  projection  of  liver. 

The  diagnosis  of  enlargement  of  the  gall-bladder  from 
movable  right  kidney  is,  as  a  rule,  easy  in  thin  persons ; 
but  in  those  who  are  stout,  or  have  tense  or  strong  muscular 
abdominal  walls,  difficulties  may  and  do  arise,  which  can, 
however,  usually  be  overcome  by  examination  under  an 
anaesthetic. 

They  resemble  one  another  in  that  each  forms  a  moderate- 
sized,  distinctly-defined,  rounded  and  movable  tumour  on 
the  right  side  of  the  abdomen,  which  is  found  to  descend 
on  inspiration. 

The  previous  history  may  throw  light  on  the  case,  especially 
if  there  have  been  definite  cholelithic  attacks  or  the  presence 
of  jaundice. 

By  inspection  of  the  abdomen,  a  gall-bladder  tumour  is 
often  apparent,  moving  rhythmically  with  the  respiratory 
movements  when  the  patient  is  recumbent ;  but  a  floating 
kidney  can  rarely  be  so  detected. 

The  general  outline  of  the  tumour  as  detected  by  palpa- 
tion may  afford  valuable  assistance;  thus,  in  distension  of  the 
gall-bladder  the  tumour  formed  is  pear-shaped,  with  the  apex 
towards  the  fissure  of  the  gall-bladder,  and  its  long  axis  in  a 
line  from  about  the  tip  of  the  ninth  costal  cartilage  down- 
wards, forwards,  and  inwards  towards  a  point  a  little  below 
the   umbilicus.      In  floating    kidney,    especially    in   patients 

12 


i78    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

with  lax  abdominal  walls,  the  tumour  may  be  grasped  and 

its  characteristic  shape  made  evident. 

Should  adhesive  peritonitis   accompany   the   gall-bladder 

condition,  there  will  be  tenderness  and  pain  on  pressure  over 

the  tumour,  especially  near  its  apex.     These  signs  are  rarely, 

if  ever,  present  in  floating  kidney. 

The  gall-bladder  tumour  can  easily  be  moved  to  a  limited 

extent    inwards  and   outwards  by  manipulation,  but    under 

no  circumstance  can  it  be  depressed  into  the  pelvis.      On 

relieving  it  of  pressure  it  tends  to  resume  its  old  position 

under  the  liver. 

Floating  kidney  has  a  generally  wider  movement,  can  at 

times  be   depressed   into  the  pelvis,  and  when   relieved   of 

pressure  tends  to  pass  towards  the  right  loin,  especially  when 

the  patient  is  recumbent. 

A  valuable  diagnostic  sign  is  the  sulcus  often  felt  between 

the  lower  margin  of  the  liver  and  the  gall-bladder  tumour  ; 

this  can  usually  be  felt  when  the  warm  flat  hand  is  placed 

over  the  upper  part  of  the  swelling  and  the  patient  is  asked 

to  breathe  deeply. 

In  the  case  of  renal  tumour,  as  well  as  in  movable  kidney, 
by  distending  the  intestine  with  gas  the  kidney  will  be  pressed 
back  into  the  loin,  but  the  gall-bladder  will  be  pushed  up 
towards  the  liver  and  made  more  prominent.  The  last  test 
is  usually  also  sufficient  to  enable  a  diagnosis  to  be  made 
between  a  distended  gall-bladder  and  a  tumour  of  the  right 
suprarenal  body  ;  but  this  is  not  always  reliable,  as  in  a 
case'*  I  saw  with  the  late  Dr.  Kebbel,  of  Flaxton,  the  applica- 
tion of  Ziemssen's  test  pushed  the  swelling  upwards,  and  on 
performing  abdominal  section,  a  sarcoma  of  the  suprarenal 
capsule  was  found  and  removed,  the  explanation  being  that 
the  colon  was  fixed  below  the  growth  and  pushed  it  up  when 
the  bowel  was  distended  with  gas. 

In  tumour  of  the  intestine  or  of  the  pylorus,  the  associated 
stomach  or  bowel  symptoms  are  usually  sufficient  to  enable 
a  diagnosis  to  be  made,  but  when  in  doubt,  distension  of  the 
stomach  or  bowel  with  gas  will  help  to  clear  it  up,  or 
examination  under  an  anaesthetic  will  afford  assistance. 
*  British  Medical  Journal,  August  26,  1899. 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     179 

Tumour  of  the  liver  itself,  either  cancer  or  hydatid  disease, 
may  be  almost  indistinguishable  from  one  of  the  gall-bladder  ; 
though  the  presence  of  nodules  in  the  liver,  with  the  history 
and  other  symptoms  of  malignant  disease,  will  usually  be 
sufficiently  distinctive  in  cancer,  while  the  less  localized  and 
more  generally  fluctuating  swelling,  together  with  the  longer 
history  and  absence  of  pain  or  tenderness,  will  distinguish 
hydatid  tumour. 

It  should  not  be  forgotten  that  the  right  lobe  of  the  liver 
may  have  an  abnormal  projection,  either  in  the  site  of  the 
gall-bladder  or  to  the  right  of  that  position,  which  may  at 
first  be  mistaken  for  an  enlarged  gall-bladder  ;  but  the 
absence  of  symptoms,  together  with  careful  bimanual  palpa- 
tion, will  usually  enable  a  correct  diagnosis  to  be  made,  and, 
as  Professor  Riedel  has  pointed  out,  the  gall-bladder  may 
frequently  be  felt  apart  from  the  swelling,  or  at  the  top  of  it 

Puncture  with  an  exploring  syringe  would,  of  course,  give 
valuable  information,  but  this  should  not  be  lightly  under- 
taken, as  it  is  not  devoid  of  risk,  death  having  occurred  on 
more  than  one  occasion  as  a  direct  result  of  this  apparently 
slight  operative  procedure. 

If  it  is  decided  to  employ  an  exploring  needle,  the  aspirator 
should  always  be  used,  in  order  that  the  tense  cyst  may  be 
completely  emptied,  otherwise  leakage  from  the  puncture  is 
almost  certain  to  occur.  In  cases  where  the  abdomen  has 
been  opened  we  have  seen  a  puncture  of  the  tumour  by  a 
small  exploratory  syringe  to  pour  out  fluid  in  a  forcible  stream, 
showing  what  would  have  occurred  had  the  puncture  been 
made  through  an  unopened  abdomen. 

In  case  of  doubt,  especially  where  the  symptoms  demand 
interference,  exploration  of  the  tumour  through  a  small 
abdominal  incision  can  be  undertaken  with  very  little  risk, 
and  at  the  same  time  further  treatment  where  called  for  can 
be  carried  out. 

Of  the  tumours  dependent  on  new  growth,  cancer  of  the  gall- 
bladder is  the  most  important,  innocent  growth,  except  of 
inflammatory  origin,  being  extremely  rare  ;  unless  it  be  true, 
as  Zenker  (Musser's  quotation)  suggests,  that  an  adenoma 
first  develops  in  the  gall-bladder  and  subsequently  becomes 

12 — 2 


I  So    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

transformed  into  an  adeno-carcinoma.  Dr.  Rolleston*  has 
reported  a  case  in  which  this  sequence  apparently  occurred 
in  the  bile-duct  of  a  woman  from  whom  a  papilloma  was 
removed,  the  growth  being  in  immediate  contact  with  a  gall- 
stone. After  some  months  she  returned  with  a  growth  in 
the  same  region,  presumably  malignant. 

Cancer  of  the  gall-bladder  is  not  nearly  so  uncommon  as  was 
once  believed,  but  as  a  primary  affection  is  somewhat  rare. 
It  is  usually  secondary  to  gall-stones,  or  to  cancer  of  adjoin- 
ing organs,  and  in  the  latter  case  is  not  amenable  to  surgical 
treatment. 

Musser  collected  the  reported  cases,t  and  Dr.  Rolleston 
has  published  two  extremely  interesting  papers  (to  which  we 
have  been  much  indebted)  on  the  subject,  one  in  the  Medical 
Chroniclel  and  the  other  in  the  Clinical  Journal.^ 

The  tumour  may  be  of  three  varieties : 

(a)  Columnar-celled  carcinoma ; 

(b)  Spheroidal-celled  carcinoma ; 

(c)  Squamous  epithelioma. 

The  existence  of  squamous-celled  epithelioma  in  the  gall- 
bladder has  been  doubted  ;  but  the  appearances  in  the  case 
described  and  figured  below  (Fig.  48)  seem  to  be  conclusive. 
Dr.  Rolleston  explains  the  appearances  shown  in  such  cases 
by  saying,  '  In  transitional  parts  the  epithelial  cells  may  be 
so  far  modified  as  to  appear  flattened,  and  have  then  been 
described  as  squamous  cells,'  and  it  is  possible  his  explana- 
tion is  the  true  one,  but  the  question  can  scarcely  be  decided 
on  the  evidence  at  present  available.  The  growth  is  said 
usually  to  begin  at  the  fundus,  where  the  irritation  from  gall- 
stones would  be  most  felt ;  but  it  may  occur  first  at  the  neck 
of  the  gall-bladder,  or  it  may  be  found  as  a  uniform  thicken- 
ing of  the  walls  of  that  viscus.  In  the  last  case  there  is 
often  found  in  the  centre  of  the  mass  a  cavity  containing 
gall-stones ;  while  where  the  neck  of  the  gall-bladder  is  the 
primary  seat,  it  is  usual  to  find  a  gall-stone  impacted  just 

*  Medical  Chronicle,  January,  1896. 

t  Boston  Medical  and  Surgical  Journal)  December  15,  1889. 
%  Medical  Chronicle,  January,  1896. 
Clinical  Journal^  April  7,  1897. 


PLATE  XXI. 


6—  * 


•  3 


■,     *  ■  '    His    STr  -J.V^ 


—V/ 


>*, 


Fig.  48. — Microscopic  Section  of  the  New  Growth. 

(Hartnach  Obj.,  No.  4,  Oc.  3  =  x  120.     Drawn  by  J.  W.  Haigh.) 

1,  1,  1,  Connective  tissue  of  alveolar  walls;  2,  connective  tissue  nuclei; 
3,  epithelial  cells,  somewhat  squamous  in  appearance  ;  4,  4,  nuclei  of  ditto  ; 
5,  smaller,  rapidly-growing  cells  of  basement  layer  ;  6,  6,  degenerated 
epithelial  cells,  in  which  the  nuclei  have  disappeared. 

To  face  p.  180.] 


PLATE  XXII. 


Fig.  49. — Carcinoma  of  Gall-bladder. 
(No.   2,265,   St.  Bartholomew's   Museum.) 


Fig.  50. — Cancer  of  Gall-bladder  Invading  Liver. 
(No.  E.  308,  Leeds  Museum.) 


To  face  p.  180.] 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS    181 

beyond  the  disease,  which  would  appear  to  have  started  as  a 
result  of  the  local  irritation  (Case  232). 

Brault  (quoted  by  Morin,  These  de  Paris,  1896)  considers 
that  squamous-celled  epithelioma  of  the  gall-bladder  is 
secondary  to  a  small  primary  growth  in  the  skin  which  has 
passed  unnoticed. 

Deetz  (Virch.  Archiv.,  Bd.  clxiv.,  p.  381)  reports  four  cases 
of  stratified  epithelial  cancer  of  the  gall-bladder ;  in  two  a 
primary  growth  was  found,  the  one  a  cylindrical  epithelial 
cancer  of  the  rectum,  the  other  an  adeno-carcinoma  of  the 
common  bile-duct.  The  gall-bladder  growths  showed  in  all 
the  cases  the  typical  structure  of  stratified  epithelial  cancer 
with  cell-nests,  and  in  three  prickle  cells  were  found.  Deetz 
considers  that  the  only  possible  explanation  is  the  direct 
transformation  of  cylindrical  into  stratified  epithelium  under 
the  influence  of  abnormal  chronic  irritation.  This  must  be 
a  rare  occurrence,  since  in  a  careful  examination  of  300 
gall-bladders  he  never  found  stratified  epithelium,  even  in 
cases  where  gall-stones  were  present. 

Bret  (Lyon  Medicate,  September,  1898)  reports  a  case  of 
primary  cancer  of  the  gall-bladder  in  which  the  growth  on 
microscopic  examination  showed  in  some  places  typical 
columns  of  squamous-celled  epithelioma,  some  of  the  cells 
showing  imbrication,  and  in  others  cylindrical  cells,  in  some 
of  which  colloid  changes  were  manifest. 

The  columnar -celled  form  may  project  into  the  gall- 
bladder, and  fill  it  with  a  villous  or  papillomatous  growth. 

Specimen  No.  2,265  in  St.  Bartholomew's  Museum  shows 
a  soft  carcinoma  in  the  gall-bladder  budding  from  the  mucous 
membrane  in  a  polypoid  form  (Fig.  49). 

No.  2,266a,  St.  Bartholomew's,  also  shows  an  epithelio- 
matous  papillary  growth  in  the  gall-bladder,  and  secondary 
cancerous  growths  in  the  liver. 

No.  E  308,  Leeds  Museum,  shows  a  similar  condition 
(Fig.  50). 

No.  2,264,  St.  Bartholomew's,  shows  a  gall-bladder  con- 
verted into  a  mass  of  medullary  cancer,  in  the  centre  of 
which  are  four  faceted  gall-stones.  The  pylorus  is  adherent- 
It  was  taken  from  a  woman  of  fifty-nine  who  suffered  from  a 


1 82    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

dilated  stomach,  but  had  no  serious  symptoms  until  a  month 
before  death.     She  was  never  jaundiced. 

Extension  of  the  growth  is  usually  by  continuity,  the  liver, 
as  a  rule,  being  first  affected  by  its  spread ;  but  the  colon  very 
frequently  is  the  organ  first  attacked  when  the  growth  has 
originated  at  the  fundus  of  the  gall-bladder.  Where  the 
tumour  arises  at  the  neck,  the  pylorus,  as  might  be  expected 
from  the  anatomical  relations,  is  not  infrequently  soon 
affected,  and  there  may  follow  all  the  symptoms  of  cancer 
of  the  pylorus. 

Where  the  gall-bladder  becomes  attached  to  any  hollow 
viscus  a  fistula  is  apt  to  form  (see  p.  131). 

The  disease  may  spread  along  the  mucous  membrane  and 
affect  the  ducts,  and  give  rise  to  obstructive  symptoms. 

At  times,  though  rarely,  the  peritoneum  becomes  infected, 
and  there  then  rapidly  follow  ascites,  and  obstruction  of  the 
veins  of  the  lower  extremities. 

The  lymph  glands  at  the  hilum  are  usually  affected,  but 
systemic  infection  is  rare. 

The  very  frequent  association  of  cancer  of  the  gall-bladder 
with  gall-stones  is  an  undoubted  fact,  and  in  all  probability 
there  is  a  connection  between  the  two  diseases. 

Zenker*  found  gall-stones  in  85  per  cent,  of  cancers  of  the 
gall-bladder,  and  Musser,  from  an  analysis  of  100  cases,  gives 
the  proportion  associated  with  gall-stones  as  69  per  cent., 
which  may,  however,  be  an  underestimate,  as  it  is  well 
known  that  gall-stones  may  produce  serious  irritation,  and 
then  pass  into  the  alimentary  canal,  so  that  their  effects  may 
remain,  although  the  cause  may  not  be  discovered.  Case  12 
is  an  illustration  of  this,  where,  following  on  symptoms  of 
gall-stones  of  several  years'  duration,  came  a  distended  gall- 
bladder, which  at  the  operation  was  found  to  be  due  to 
cancer  of  the  bile-duct,  all  the  gall-stones  having  been 
passed. 

Courvoisier  found  gall-stones  present  in  74  out  of  84  cases 
of  primary  cancer  of  the  gall-bladder;  Brodowski  (Naunyn, 
P-  x53)  m  I0°  Per  cent. ;  Jayle  (Soc.  Anat.,  1893)  in  23  out 
of  30 ;  Bertrand  in  14  out  of  15  ;  and  Siegert  in  95  per  cent. 

*  Deutsch.  Arch,  fur  Klin.  Med.,  1899. 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS    183 

of  primary,  but  only  in  15  or  16  per  cent,  of  secondary,  car- 
cinoma of  the  gall-bladder. 

According  to  Schroeder,  14  per  cent,  of  all  cases  of  gall- 
stone patients  suffer  at  some  time  from  cancer  of  the  biliary 
passages,  and  Naunyn  is  of  opinion  that  half  the  cases  of 
chronic  jaundice  diagnosed  as  cholelithiasis  are  complicated 
with  cancer  or  are  due  to  cancer  alone,  but  the  correctness 
of  the  observations  is,  in  our  opinion,  somewhat  doubtful. 
The  frequent  association  of  malignant  disease  is,  however, 
of  extreme  importance,  since  operation  in  the  presence  of 
cancer  and  chronic  jaundice  is  attended  with  more  danger 
than  in  simple  cases. 

The  two  theories  which  have  been  current  to  explain  the 
co-existence  of  gall-stone  with  cancer  of  the  liver  are  : 
first,  the  '  irritation '  theory,  that  gall-stones  are  formed 
first,  and,  by  acting  as  foreign  bodies,  set  up  irritation,  which 
leads  to  malignant  growth  ;  and,  second,  the  '  concentration  ' 
theory,  that  gall-stones  arise  as  a  secondary  result,  from 
stagnation  of  bile  in  the  ducts  and  infection  of  the  bile 
passages,  caused  by  their  obstruction  from  malignant  growth. 
It  is,  however,  doubtful  whether,  apart  from  a  catarrhal  con- 
dition of  the  mucous  membrane,  gall-stones  are  formed.  It 
should  be  remembered  that  the  cholesterin  in  gall-stones  is 
derived,  in  all  probability,  not  from  that  present  in  the 
normal  bile,  but  from  the  mucous  membrane. 

Mr.  C.  Beadles,  in  a  paper*  before  the  Pathological  Society 
of  London,  stated  that  out  of  100  post-mortem  examinations 
at  the  Cancer  Hospital,  4  were  cases  of  primary  carcinoma 
of  the  liver,  and  all  had  calculi  in  the  gall-bladder ;  36  had 
secondary  carcinomatous  growths  in  the  liver,  but  there  were 
no  gall-stones  present  in  any  of  them.  Of  9  cases  of  primary 
carcinoma  of  the  liver  at  Colney  Hatch,  5  were  males  and 
4  females,  and  gall-stones  were  present  in  7,  being  absent 
in  1  male  and  1  female.  These  facts  support  the  theory  of 
irritation,  as  does  also  the  fact  that  the  disease  occurs  much 
more  frequently  in  women  than  in  men,  and  in  much  the 
same    relative    proportion    as    gall-stones.       Musser's    cases 

*  Lancet,  March  9,  1895. 


1 84    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

included  75  females  and  23  males ;  while  Siegert  found  that 
of  93  cases  79  were  in  females. 

Symptoms  and  Signs  of  Cancer. — If  the  growth  be  primary, 
there  will  be  the  history  of  a  more  or  less  rapidly  growing 
tumour  developing  under  the  right  costal  margin,  accom- 
panied at  first  by  a  sense  of  discomfort,  shortly  changing  to 
pain,  which  is  often  worse  at  night,  and  which,  though  at 
first  localized  to  the  right  hypochondrium  and  epigastrium, 
usually  before  great  advance  has  been  made  extends  round 
the  side  to  the  right  infrascapular  region.  When  the  en- 
largement is  first  noticed,  it  is  felt  as  an  egg-shaped  swelling 
beneath  the  liver,  descending  on  inspiration.  The  tumour  is 
hard  to  the  touch,  and  very  slightly  or  not  at  all  tender  to 
pressure.  At  a  later  stage  it  becomes  more  fixed  and  more 
diffused,  and  nodules  may  develop  and  be  felt  on  its  superficial 
surface.  As  the  growth  extends,  it  invades  the  liver,  and 
sometimes  the  duodenum,  colon,  and  stomach.  Dissemination 
is  rare.  When  it  occurs,  nodules  may  be  found  in  the  liver, 
and  generally  over  the  peritoneum.  In  such  cases  ascites 
develops.  The  lymph  glands  in  the  hilum  of  the  liver 
usually  become  affected. 

According  to  the  invasion  or  not  of  the  hepatic  or  common 

bile-ducts,    so   will   be   the  presence  or  absence  of  marked 

jaundice  ;  but  in  nearly  half  of  the  cases  some  degree  of  icterus 

will  be  found  as  the  disease  advances,  owing  to  the  presence 

of  catarrh  of  the  bile-ducts. 

Interference  with  the  action  of  the  bowels,  even  to  partial 
or  complete  obstruction,  at  times  occurs.  General  failure  of 
health,  continued  wasting,  with  loss  of  strength,  ascites,  and 
marked  cachexia,  characterize  the  later  stages. 

Perforation  may  occur  and  hasten  the  end  by  the  onset  of 
general  peritonitis.  If  gall-stones  be  present,  there  will  be 
the  usual  antecedent  history  of  cholelithiasis.  Where  gall- 
stones with  jaundice  complicate  cancer  of  the  gall-bladder, 
exacerbations  of  pain  will  usually  be  accompanied  by  rigors 
and  fever,  '  ague-like  attacks '  with  an  intensification  of  the 
icterus,  and  in  such  cases  petechias  in  the  skin  with  haemor- 
rhage from  the  nose  and  rectum  generally  supervene. 

Diagnosis. — Cancer   of  the   gall-bladder    may    usually   be 


TUMOURS  OF  THE  GALL-BLADDER  AND  DILE-DUCTS     185 

diagnosed  by  the  progressive  character  of  the  disease,  and  by 
the  presence  of  the  characteristic  hard  tumour ;  but  it  is  by 
no  means  always  easy  to  diagnose  cancer  from  a  tumour 
formed  by  matted  intestines,  due  to  local  peritonitis  in  the 
neighbourhood  of  the  gall-bladder. 

In  a  doubtful  case  of  this  kind,  in  a  woman  of  fifty,  under 
my  care  in  the  Leeds  Infirmary,  when  the  abdomen  was 
opened  there  was  found  what  appeared  to  be  a  malignant 
tumour  of  the  gall-bladder,  which  was  punctured  in  several 
places  with  an  exploring  syringe.  Finding  it  firm  and  hard, 
it  was  concluded  to  be  malignant,  and,  as  it  was  too  exten- 
sive for  removal,  the  abdomen  was  closed,  since  it  was  thought 
nothing  more  could  be  done.  The  patient,  however,  forth- 
with recovered,  and  is  now  well,  with  no  remnant  of  her 
tumour.  It  is,  of  course,  impossible  to  say  that  this  was  not 
cancer,  but  in  all  probability  it  was  an  inflammatory  swelling 
associated  with  gall-stones  (Case  46). 

In  another  case  of  tumour,  where  there  was  a  suspicion  of 
malignancy,  an  abscess  of  the  liver  containing  thirty  gall- 
stones was  opened,  and  this  gave  marked  relief,  though  only 
for  a  time,  as  death  supervened  four  months  later,  when 
malignant  disease  was  found.  When  in  doubt,  exploration 
is  probably  the  best  method  of  settling  the  question,  as  at 
the  same  time  treatment  may  be  carried  out,  as  in  Cases 
56  and  57. 

That  cancer  of  the  right  suprarenal  body  may  afford  a 
difficulty  in  diagnosis  is  shown  by  the  case  referred  to  in  the 
chapter  on  simple  tumours  of  the  gall-bladder.  The  same 
difficulty  applies  to  cancer  of  the  pylorus,  which,  however, 
is  accompanied  for  the  most  part  by  characteristic  stomach 
symptoms. 

Treatment. — The  alleviation  of  symptoms,  especially  of 
pain  by  sedatives,  is  usually  all  that  can  be  done,  except  in 
those  rare  cases  where  the  disease  is  limited  to  the  gall- 
bladder, when  cholecystectomy  may  be  performed. 

For  instance,  specimen  No.  2,265,  Bartholomew's,  is 
taken  from  a  case  in  which  the  whole  disease  could  have  thus 
been  removed,  if  it  could  have  been  diagnosed  (Fig.  49). 

In  a  limited  number  of  cases  in  which  the  liver  is  affected 


1 86    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


by  direct  extension  from  the  gall-bladder,  it  may  appear 
feasible  to  remove  the  whole  disease.  In  such,  it  is  probably 
right  that  the  patient  should  get  what  chance  there  is  of 
complete  cure,  though  in  all  probability,  as  might  be  ex- 
pected, this  is  but  slight.  As  illustrating  the  kind  of  cases 
suitable  for  such  treatment  and  the  nature  of  the  procedure 
which  may  be  necessary,  the  following  notes  of  cases  may 
be  useful : 

Case  127). — The  patient,  a  woman  of  fifty-four,  gave  the 


Fig.    51. — Excision   of    a    Portion    of    Liver   for   Tumour.       (reduced 

one-third.) 

G.B.O.,  Outer  surface  of  gall-bladder  ;  near  x  the  growth  is  infiltrating  the 
wall,  shown  in  shaded  portion  ;  B.W.,  thickened  and  infiltrated  wall  of 
gall-bladder,  laid  open;  L,  liver;  LS,  liver  laid  open  to  show — N, 
secondary  malignant  nodule  in  liver;  D,  cystic  duct.  (Trans.  Roy.  Med. 
and  Chir.  Soc,  vol.  lxxix.) 

history  of  having  had  an  enlarged  gall-bladder  for  twelve 
years,  which  had  given  no  trouble  until  three  years  before, 
from  which  time  she  had  had  gall-stone  attacks.  For  four 
months  she  had  been  failing  in  health,  and  when  seen  the 
gall-bladder  reached  the  right  groin,  and  the  right  lobe  of 
the  liver  the  level  of  the  umbilicus. 

She  was  operated  on  on  November  23,  1895,  and  on  open- 
ing the  gall-bladder  the  walls  were  found  infiltrated  with 
growth  and  the  contents  putty-like  in  consistence.  The 
entrance  to   the  cystic  duct  was  occluded  by  a  growth  the 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     187 

size  of  a  walnut,  and  beyond  this  a  gall-stone  could  be  felt 
in  the  cystic  duct.  As  there  was  a  nodule  of  growth  on  the 
under  surface  of  the  liver  close  to  the  one  in  the  neck  of  the 
gall-bladder,  the  whole  mass  was  pulled  forward  and  en- 
circled with  an  elastic  ligature,  which  was  passed  below  the 
gall-stone  so  as  to  get  well  beyond  the  growths,  retraction 
being  prevented  by  two  knitting-needles  pushed  through  the 
projecting  liver. 

The  projecting  portion  was  then  cut  away  ;  it  included 
liver,  gall-bladder,  and  part  of  the  cystic  duct,  and  weighed 
half  a  pound.  Recovery  was  uninterrupted,  and  the  tem- 
perature never  reached  ioo°  F.  The  growth,  on  examination 
by  Mr.  J.  W.  Haigh,  was  reported  to  be  epithelioma.  The 
case  is  fully  reported  in  the  seventy-ninth  volume  of  the 
Trans.  Roy.  Med.  and  Chir.  Soc.  (Figs.  48  and  51). 

Case  201.— Mrs.  H.,  aged  fifty-two,  gave  a  history  of  re- 
peated severe  attacks  of  pain  in  right  hypochondriac  region 
during  twelve  months,  sometimes  followed  by  jaundice. 
Preceding  this  there  had  been  attacks  of  '  spasms '  for  some 
considerable  time.  A  month  before  coming  under  treatment 
a  swelling  was  noticed  under  the  right  costal  margin.  The 
patient  had  been  losing  weight  and  strength  for  several 
months,  and  was  suffering  from  slight  jaundice,  which 
became  intensified  after  each  attack  of  pain,  these  seizures 
being  followed  by  a  feeling  of  chilliness  with  some  fever.  It 
was  quite  easy  to  make  out  an  enlargement  of  the  right  lobe 
of  the  liver  with  a  distended  gall-bladder  on  its  inner  side. 
The  abdomen  was  opened  through  the  right  semilunar  line 
on  November  27,  1897,  and  the  gall-bladder  was  found 
enormously  distended  with  putty-like  material,  which  had 
to  be  removed  by  a  scoop.  The  gall-bladder  also  contained 
four  gall-stones.  After  numerous  adhesions  had  been  de- 
tached, there  was  felt  an  enlargement  of  the  cystic  duct,  and 
below  this  an  impacted  gall-stone.  Closely  adjoining  the 
gall-bladder  a  nodule  of  cancer  was  seen  in  the  liver,  which 
was  also  infiltrated  opposite  the  growth  in  the  cystic  duct. 
The  right  border  of  the  liver,  which  projected  well  below  the 
ribs,  and  the  gall-bladder  and  cystic  duct,  were  now  dragged 
forward,  and  a  knitting-needle  was  thrust  through  the  liver 


1 88    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

and  through  the  cystic  duct  below  the  disease,  the  whole 
being  then  encircled  by  an  elastic  tourniquet,  which  was  tied 
and  cut  off  short.  The  abdomen  was  then  wiped  dry,  and 
the  rest  of  the  wound  closed.  The  portion  of  liver,  gall- 
bladder, and  cystic  duct  beyond  the  ligature  were  then  cut 
away,  and  apparently  the  whole  of  the  disease  was  removed, 
as  no  nodules  could  be  seen  on  any  other  part  of  the  liver. 
The  patient  made  a  somewhat  tardy  recovery,  from  the  per- 
sistence of  the  ague-like  attacks  which  had  been  associated 
with  the  infective  cholangitis  present  before  operation. 

The  needle  and  tourniquet  separated  in  a  fortnight,  and 
after  that  there  was  free  discharge  of  bile  for  a  time,  giving 
great  relief,  and  leading  to  the  cessation  of  the  ague-like 
seizures.  The  patient  regained  her  flesh  and  strength,  and 
had  a  period  of  good  health  until  March,  1898,  when  a  small 
nodule  was  noticed  in  the  skin  below  the  umbilicus,  together 
with  some  swelling  in  the  inguinal  glands.  In  April  there 
was  a  little  ascites,  and  from  this  time  her  health  rapidly 
failed,  and  she  died  from  exhaustion  in  July,  1898.  The 
portion  of  liver  removed  weighed  7  ounces,  and  then  did  not 
include  the  large  amount  of  soft  material  removed  from  the 
gall-bladder.  Under  the  microscope  the  growth  proved  to 
be  carcinoma. 

Case  208). — Mrs.  B.,  aged  fifty-two,  was  admitted  to  the 
Leeds  Infirmary  in  February,  1899,  complaining  of  slight 
attacks  of  abdominal  pain  beginning  in  the  previous 
September,  and  being  specially  severe  in  December.  There 
had  been  very  rapid  loss  of  flesh,  and  by  the  time  of  her 
arrival  at  the  hospital  she  was  extremely  ill.  Icterus  was 
slight,  but  there  was  a  large,  irregular,  hard,  and  fixed  tumour 
beneath  the  right  costal  margin,  manifest  to  sight  and  tender 
on  pressure.  At  the  operation  the  gall-bladder  and  cystic 
duct  were  found  filled  with  pus,  epithelial  debris,  and  gall- 
stones. The  walls  of  the  gall-bladder  were  infiltrated  with 
growth,  which  extended  into  the  adjoining  part  of  the  liver. 
The  omentum,  pylorus,  hepatic  flexure  of  the  colon,  and 
duodenum  were  all  adherent,  probably  by  cancerous  infiltra- 
tion ;  but,  when  they  had  been  separated,  it  was  deemed 
wise  to  complete  the  operation,  as  in  the  two  previous  cases, 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     189 

by  means  of  elastic  ligature  and  external  treatment  of  the 
pedicle.  The  patient  was  put  back  to  bed  in  good  condition, 
and  seemed  as  if  she  would  do  well,  but  in  the  night  she 
rapidly  lost  strength,  and  despite  transfusion,  injection  of 
strychnine,  and  the  use  of  other  means,  she  died  from  shock. 

Examination  of  the  parts  after  death  showed  that  the 
whole  of  the  disease  in  the  gall-bladder  and  liver  had  been 
removed. 

Case  273. — Mr.  A.  13.,  aged  forty-six,  had  suffered  from 
attacks  of  cholelithic  colic  for  five  years  before  coming 
under  observation  toward  the  end  of  1897.  At  that  time  it 
was  considered  that  there  was  a  gall-stone  in  the  common 
duct,  and  he  was  advised  to  submit  himself  to  operation  ; 
but,  acting  on  other  medical  advice,  he  decided  not  to  do  so. 
By  the  middle  of  1899  he  had  lost  4  stones  in  weight,  and 
was  extremely  weak.  Jaundice  was  present,  and  there  was 
evidence  of  infective  cholangitis. 

At  the  operation  on  June  26,  1899,  there  were  found  a 
large  number  of  gall-stones  in  the  common  duct,  and  a 
tumour  of  the  liver  just  at  the  point  of  attachment  of  the 
fundus  of  the  gall-bladder.  The  mass,  which  was  hard  and 
irregular,  was  excised  partly  by  the  use  of  the  knife  and  in 
part  with  scissors.  The  bleeding,  which  was  not  very  severe, 
was  controlled  by  pressure ;  only  one  vessel,  an  artery,  re- 
quiring to  be  ligatured.  A  sponge  was  packed  into  the 
cavity  left,  while  the  gall-stones  in  the  common  duct  were 
crushed,  and  cholecystenterostomy  was  performed  by  means 
of  a  Murphy's  button,  the  remains  of  the  gall-bladder  just 
beyond  the  cystic  duct  being  anastomosed  to  the  duodenum. 
The  wound  in  the  liver,  which  measured  about  4  inches 
across,  was  as  far  as  possible  brought  together  by  catgut 
stitches  placed  deeply  by  means  of  an  ordinary  round,  curved 
needle,  and  tied  slowly,  the  remaining  part  of  the  cut  surface 
of  the  liver  being  packed  with  iodoform  gauze.  On  the 
second  day  a  considerable  amount  of  bile  escaped  along  the 
gauze,  and  this  continued  to  discharge  for  ten  days,  but  in 
gradually  diminishing  quantity.  After  this  time  only  serum 
escaped.  The  first  packing  was  removed  on  the  fourth  day, 
and  thereafter  the  wound  was  dressed  twice  daily  for  ten 


i go    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

days,  and  once  a  day  from  the  end  of  the  fortnight  till  it 
healed.  Sixty-two  gall-stones  were  passed  per  rectum  on 
the  tenth  and  eleventh  day  without  any  pain.  The  Murphy 
button  came  away  on  the  twenty-third  day.  The  patient 
left  the  nursing  home  five  weeks  from  the  date  of  the  opera- 
tion, and  has  since  been  very  well.  On  August  29  he 
reported  that  he  had  gained  a  stone  in  weight  since  the 
operation.  A  microscopic  examination  showed  the  tumour 
to  be  a  spheroidal-celled  carcinoma.  The  after-history  of 
the  patient  is  most  interesting,  in  that  he  is  in  perfect  health 
at  this  date,  nearly  five  years  after  operation. 

Case  367. — E.  H.,  aged  thirty-seven  ;  seen  at  the  Leeds 
General  Infirmary.  History  of  attacks  of  biliary  colic  for 
five  years.  Lately  the  attacks  had  been  followed  by  jaun- 
dice. No  loss  of  weight.  A  hard,  rounded  tumour  felt  in 
the  region  of  the  gall-bladder. 

Operation,  April  12,  1901. — The  gall-bladder  w^as  enlarged, 
containing  a  dozen  gall-stones  and  muco-purulent  fluid. 
After  removing  the  fluid  and  stones,  the  whole  of  the  gall- 
bladder was  found  to  be  infiltrated  with  malignant  disease. 
The  growth  was  extending  into  the  surrounding  liver  sub- 
stance. 

Three  stout  pins  were  passed  through  the  substance  of  the 
liver,  about  ih  inches  beyond  the  growth,  and  a  stout  rubber 
ligature  was  tied  tightly  around  the  liver  substance.  The 
protruding  portion,  consisting  of  the  gall-bladder  and 
adjacent  liver  tissue,  was  then  amputated,  and  the  rest  of 
the  wound  closed.  The  patient  made  a  good  recovery,  and 
left  the  hospital  on  May  14. 

Case  330. — Mrs.  S.,  aged  sixty-three.  History  of  pain 
and  tumour  associated  with  jaundice.  Great  loss  of  flesh 
and  strength. 

Operation,  August  10,  1900. — Mass  of  growth  discovered  in 
liver,  gall-bladder,  and  pylorus.  Cholecystectomy,  pylorec- 
tomy,  and  partial  hepatectomy  performed.  Good  recovery. 
Patient  well  and  in  good  health  June,  1903. 

Microscopic  examination  showed  the  growth  to  be  a  car- 
cinoma. 

*  Case  reported  in  exte?iso  in  British  Medical  Journal,  April  13,  1901. 


TUMOURS  OF  THE  GALL-BLADDER  AND  DILE-DUCTS     191 

Other  cases  will  be  found  reported  in  the  Appendix 
(Nos.  340,  344,  485,  and  528). 

Moynihan  {British  Medical  Journal,  November  8,  1902) 
reports  the  following  case  of  primary  carcinoma  of  the  gall- 
bladder: 

Mrs.  A.,  aged  sixty.  Two  years  ago  the  patient  had  an 
attack  of  hepatic  colic,  followed  by  jaundice.  No  stone  was 
found.  Six  months  ago  a  second  attack,  and  a  fortnight  ago 
a  third  attack.  In  each  attack  the  pain  has  been  acute, 
sickening,  and  of  several  hours'  duration,  and  after  each 
jaundice  has  appeared.  After  the  last  attack  a  tumour  was 
noticed  in  the  right  hypochondrium.  It  seemed  about  the 
size  of  a  billiard  ball,  was  not  in  the  least  degree  tender, 
and  moved  very  freely  in  all  directions,  as  though  only 
held  by  a  stalk  to  the  liver.  There  was  neither  jaundice 
nor  ascites.  A  diagnosis  of  stone  impacted  in  the  cystic 
duct,  with  consecutive  dilatation  of  the  gall-bladder,  was 
made,  though  the  entire  absence  of  tenderness  was  against 
this. 

The  abdomen  was  opened  through  the  right  rectus  muscle, 
and  the  gall-bladder  exposed.  It  was  found  densely  hard, 
adherent  to  the  omentum  by  moderately  firm  adhesions,  but 
not  bound  to  the  liver.  An  incision  in  it  showed  that  the 
enlargement  of  it  was  due  to  a  great  thickening  of  its  walls, 
the  lumen  being  small  and  having  a  capacity  of  barely  more 
than  a  drachm.  The  omental  adhesions  were  separated  and 
the  gall-bladder  freed  down  to  the  cystic  duct.  The  bladder 
and  cystic  duct  were  removed  by  cutting  through  the  latter 
close  to  its  junction  with  the  common  duct  after  a  ligature 
had  been  applied  round  it.  The  peritoneum  over  the  cut 
end  was  stitched  with  a  continuous  catgut  suture,  and  the 
abdomen  closed  without  drainage.  The  cavity  of  the  gall- 
bladder was  barely  as  large  as  a  thimble  ;  it  contained  a 
dirty  grayish-black  fluid.  No  stones  were  present,  either  in 
the  gall-bladder  or  the  cystic  duct.  A  careful  search  of  the 
hepatic  and  common  ducts  was  made,  but  no  stone  was 
found.  The  wound  healed  by  first  intention,  except  at  one 
stitch  opening,  from  which  about  10  to  20  drops  of  pus  were 
expressed    about    three    weeks    after    the    operation.     The 


1 92    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

patient  went  home  well  in  the  fourth  week,  and  her  health 
has  been  well  maintained  since. 

As  in  these  cases,  so  in  most,  the  question  of  operation 
will  usually  have  to  be  faced,  since  the  possibility  of  the 
trouble  being  dependent  entirely  on  inflammation,  the  result 
of  gall-stone  irritation,  and  not  on  new  growth,  cannot 
always  be  pre-determined.  Indeed,  even  after  the  abdomen 
has  been  opened  it  is  not  always  easy  to  be  sure  of  the  exact 
condition  of  affairs  until  adhesions  have  been  broken  down. 
It  is  not  very  uncommon  to  find  a  gall-bladder  containing 
pus  and  gall-stones  in  the  centre  of  a  mass  of  omentum  and 
adherent  viscera  so  hard  as  very  closely  to  simulate  new 
growth.  In  such  cases,  of  course,  all  that  is  necessary  in 
order  to  effect  a  cure  is  to  remove  the  stones  and  drain  the 
gall-bladder. 

Whether  it  is  worth  trying  thus  to  remove  a  localized 
cancer  of  the  liver  and  gall-bladder  is  a  question  which  can 
only  be  solved  by  more  extended  experience  ;  but  we  are 
inclined  to  think  that  in  the  cases  reported  above,  even 
when  recurrence  took  place,  the  respite  gained  to  the  patient 
more  than  counterbalanced  the  danger  of  the  operation. 
In  similar  cases,  where  no  attempt  at  radical  treatment  was 
made,  the  course  of  events  does  not  seem  to  have  been  nearly 
so  satisfactory,  for  the  disease  steadily  progressed  to  a  fatal 
termination,  and  the  patients  had  not  even  the  satisfaction  of 
a  respite,  or  the  hope  of  recovery  engendered  by  the  know- 
ledge that  the  malignant  disease  had  been  removed. 

Sarcoma  of  the  gall-bladder  is  much  less  common  than 
carcinoma,  but  it  is  occasionally  found.  Musser  (Boston 
Medical  and  Surgical  Journal,  December  15,  1889)  has  col- 
lected three  cases,  and  Kolleston  (Clinical  Journal,  April  7, 
1897)  has  reported  another,  which  on  examination  was  found 
to  be  a  case  of  spindle-celled  sarcoma.  In  the  Hunterian 
Museum,  Specimen  No.  2,809  shows  a  melanotic  sarcoma  of 
the  gall-bladder. 

Simple  growths  in  the  gall-bladder  are  as  a  rule  not  of  great 
clinical  importance,  except  as  precursors  of  malignant  disease. 
The  following  specimens  have  been  found  in  the  museums  : 

No.    2,812,   Royal    College   of  Surgeons,  shows  villi    and 


PLATE  XXIII. 


Fig.  52. — Papillomata  of  the  Gall-bladder. 
(No.  1,404,  Guy's  Museum.) 


M 


*■%- 


? 


(</ 


I'Ki-  53- — Growth  of   Gall-bladder;    Gut   Surface   of   Base. 
Rather  more  than  half  size. 


To  face  p.  193. 1 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     193 

papilla;  on  the  mucous  surface  of  the  gall-bladder  associated 
with  gall-stones. 

No.  1,404,  Guy's  Museum,  shows  papillomata  in  the  gall- 
bladder from  a  woman  of  fifty-nine  who  died  of  phthisis. 
They  are  sessile  towards  the  fundus,  and  pedunculated 
towards  the  neck  of  the  bladder  (Fig.  52). 

In  the  Museum  of  the  Western  Infirmary,  Glasgow,  is  a 
beautiful  specimen  of  adenoma  of  the  fundus  of  the  gall- 
bladder, which  has  been  described  and  figured  by  Dr.  L.  R. 
Sutherland.* 

No.  1,405,  Guy's  Museum,  shows  a  gall-bladder  in  which 
the  mucous  membrane  is  covered  with  warty  growths. 

Multilocular  Cystic  Tumour  of  Gall-bladder. — The  following 
case,  reported  by  Mr.  Stanmore  Bishop  in  the  Lancet  for 
July  13,  1901,  is  of  great  interest,  and  so  far  as  I  know  is 
unique. 

The  patient  was  a  woman,  aged  forty-two,  florid-looking, 
fairly  stout,  and  in  good  condition.  Previously  to  the  last 
two  years  she  used  to  have  almost  weekly  bilious  attacks, 
which  were  never  very  severe,  were  attended  by  transient 
jaundice,  and  had  since  that  time  entirely  disappeared.  The 
last  attack  of  jaundice  was  eight  years  ago.  Eighteen 
months  since  she  began  to  be  conscious  of  a  dull  sickly 
pain,  associated  with  a  feeling  of  weight,  not  in  the  epigas- 
trium or  right  hypochondrium,  but  in  the  left  lower  quadrant 
of  the  abdomen  and  over  the  sacrum.  The  pelvis  was  free. 
Below  the  liver,  moving  with  it  and  with  respiration,  was  a 
large  rounded  tumour,  the  dulness  of  which  on  percussion 
being  continuous  with  that  of  the  hepatic  region.  There 
had  been  no  urinary  symptoms.  There  was  no  pain  or  dis- 
comfort in  the  right  shoulder,  and  there  was  no  tenderness 
on  manipulation.  The  bowels  acted  regularly,  and  the  stools 
were  normal  in  colour. 

On  opening  the  abdomen  parallel  and  internal  to  the  right 
linea  semilunaris,  the  gall-bladder  presented.  It  formed  a 
tumour  of  the  size  of  a  child's  head,  evidently  multilocularly 
cystic,  the  contents  of  the  cyst  showing  a  bluish  colour 
through  the  thin  walls.  There  were  no  adhesions.  The 
*  Glasgow  Medical  Journal,  September,  1898. 


194    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

tumour  was  packed  around  with  sponges,  and  the  cyst 
nearest  to  the  surface  was  tapped.  Mucus  tinged  with  bile 
escaped  through  the  cannula,  but  the  swelling  was  not  per- 
ceptibly decreased.  A  second  and  deeper  cyst  was  tapped 
through  the  same  orifice,  with  the  same  result,  and  it  became 
evident  that  the  main  bulk  was  composed  of  comparatively 
small  cysts,  having  no  intercommunication.  The  opening 
in  the  abdominal  wall  was  then  enlarged,  and  the  entire 
mass  was  turned  out  of  the  cavity.  It  sprung  from  the 
under  surface  of  the  liver,  having  for  a  pedicle  apparently 
the  cystic  duct,  which  was  greatly  enlarged  by  the  growth  of 
the  tumour  downwards  into  it.  As  this  was  too  large  to 
admit  the  passage  of  a  single  constricting  ligature,  and  as  it 
appeared  probable  that  any  attempt  at  transfixing  with  liga- 
ture in  segments  might  result  in  leakage  of  its  contents  into 
the  general  peritoneal  cavity,  its  walls  were  carefully  sutured 
all  round  to  the  parietal  peritoneum,  and  that  portion  of  the 
mass  above  this  line  was  cut  away.  A  few  vessels  in  the 
walls  of  the  gall-bladder  required  ligature,  but  the  bleeding 
was  comparatively  trifling.  The  wound  was  then  closed 
around  it  as  far  as  possible.  The  remaining  base  of  the 
tumour  was  dressed  with  iodoform  gauze,  and  the  rest  of 
the  skin  wound  was  sealed  with  celloidin. 

Fig.  53  shows  the  growth  from  the  cut  surface.  Exami- 
nation of  the  tumour  showed  that  it  was  the  gall-bladder 
itself,  the  cavity  of  which  was  divided  up  by  dissepiments 
into  many  separate  spaces.  These,  as  shown  in  the  illustra- 
tion, have  been  opened  in  order  that  the  cavities  might  be 
filled  with  cotton-wool,  so  that  in  setting  it  might  retain  its 
original  shape;  but  originally  all  the  cavities  were  distinct, 
and  had  no  connection  with  one  another.  They  contained 
mucoid  fluid  stained  with  bile.  No  calculi  were  present,  and 
there  were  no  hydatids. 

The  after-course  of  the  case  threw  some  little  light  upon 
the  mode  of  origin.  The  stump  left  in  the  abdominal  wall, 
composed  of  some  part  of  the  tumour,  and  the  walls  of  the 
cystic  duct,  gradually  contracted.  The  actual  cautery  was 
applied  twice  to  the  centre,  and,  as  the  contraction  went  on, 
bile  escaped  from  the  lower  quadrant  of  the  circle,  showing 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     195 

that  the  tumour  was  not  equally  connected  all  round  its 
innermost  extremity.  It  would  appear  that  it  must  have 
started  from  the  upper  wall  of  the  bladder  or  duct,  and 
whilst  in  the  process  of  growth  it  had  blended  with  the 
lower  wall  and  fundus  of  the  gall-bladder  ;  union  had  not 
been  so  complete  in  the  duct  itself.  Microscopical  sections 
of  the  septa  and  walls  showed  dilated  glandular  tubes  of  all 
degrees.  Even  the  largest  cyst-walls  were  lined  with  cylin- 
drical epithelium.  There  had  apparently  been  hypertrophy 
of  the  mucous  lining  of  the  wall,  with  immense  development 
and  distension  of  the  glandular  layer,  but  what  caused  such 
hypertrophy  was  not  so  clear.  Was  this  an  extreme  stage 
of  a  papillomatous  degeneration,  or  was  it  a  new  formation  ? 
That  it  was  not  a  malignant  growth  seems  evident  by  the 
regular  arrangement  of  the  component  tissues  and  the 
absence  of  any  confusion  between  the  lining  epithelium 
and  the  wall  upon  which  they  rest.  No  sarcomatous  cells 
could  be  seen.  Moreover,  with  the  exception  of  the  growth 
and  some  slight  temporary  attacks  of  jaundice,  the  patient 
was  in  perfect  health.  She  had  not  lost  flesh  and  was  of  a 
clear,  healthy  complexion  at  the  time  of  operation,  nor  has 
she  lost  ground  since.  Bile,  which  is  perfectly  healthy,  still 
escapes  at  times  from  the  site  of  operation,  and  probably  a 
cholecystenterostomy  will  be  required,  but  otherwise  she  is 
perfectly  well. 


II.  TUMOURS  OF  THE  BILE-DUCTS. 

Cystic  Tumours. — Tumours  of  the  bile-ducts,  per  se,  only 
occasionally  form  a  projection  so  large  as  to  be  distinguished 
through  the  abdominal  walls.  A  tumour  is,  however,  in 
some  cases,  present  sooner  or  later  on  account  of  the  ob- 
struction in  the  ducts  and  secondary  distension  of  the  gall- 
bladder. The  common  duct  has  been  found  dilated  to  such 
a  size  as  to  form  a  cystic  tumour,  presenting  all  the  charac- 
teristics of  a  distended  gall-bladder,  the  gall-bladder  itself 
being  atrophied. 

Terrier  describes  four  cases  in  which  an  external  fistulous 

13— 2 


196    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

opening  was  established  in  the  common  bile-duct.  In  three 
of  these  the  duct  was  much  distended,  and  formed  a  distinct 
abdominal  tumour.  The  first  case  was  one  in  which  median 
laparotomy  was  performed  for  the  removal  of  a  swelling 
diagnosed  as  a  cyst  of  the  pancreas.  The  nature  of  this 
swelling  having  been  revealed  by  the  discharge  of  bile  after 
puncture,  a  small  portion  of  the  wall  of  the  cyst  was  excised, 
and  the  edges  of  this  opening  were  attached  to  the  external 
wound.  The  biliary  fistula  thus  formed  bled  freely  for  some 
days  after  the  operation,  and  subsequently  suppurated.  The 
patient  died  from  anaemia  and  exhaustion  on  the  twenty- 
ninth  day. 

In  the  second  case,  the  much-distended  duct,  which  had 
been  regarded  as  a  hydatid  cyst  of  the  liver,  was  exposed 
by  laparotomy,  incised,  and  attached  to  the  wound  in  the 
abdominal  wall.  The  patient  died  from  collapse  on  the 
eighth  day. 

In  the  third  case,  the  dilated  duct  was  opened  and  stitched 
to  the  external  wound,  under  the  supposition  that  the  tumour 
was  a  distended  gall-bladder. 

In  the  fourth  case,  it  is  not  clearly  stated  whether  the 
duct  was  distended  or  not,  though  it  probably  was.  In  this 
instance  the  hepatic  portion  of  the  divided  duct  was  fixed 
to  the  surface  of  the  abdominal  wall  after  removal  of  the 
gall-bladder,  the  cystic  duct,  and  a  small  portion  of  the  liver 
for  cancer.  The  patient  did  well  for  some  time  after  the 
operation,  but  died  six  weeks  later  from  exhaustion. 

In  his  comments  on  these  records,  Terrier  points  out  that 
in  two  of  these  cases  the  distension  of  the  bile-duct,  though 
clearly  due  to  obstruction,  was  not  associated  with  lithiasis. 
In  the  third  case  the  duct  was  found  to  be  completely 
obstructed  at  its  intestinal  orifice  by  a  small  calculus.  In 
each  instance  of  distended  bile-duct  the  gall-bladder  was 
much  shrunken,  and  its  walls  were  sclerosed  and  surrounded 
by  cicatricial  tissue. 

In  the  abstract  of  cases  given  below  there  will  be  found 
two  cases  of  this  kind.  In  one  the  operation  of  choledochos- 
tomy  was  performed  after  cholelithotrity  had  been  done,  the 
patient   making  an  excellent   recovery ;  in  the  other  chole- 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     197 

dochenterostomy,  after  cholecystectomy,  the  patient  also 
doing  well.  Both  patients  are  now  in  good  health.  (Cases 
150  and  121.) 

In  June  of  this  year  (1903)  I  saw  another  case  with 
Dr.  Griffiths,  of  Swansea,  where  there  were  two  swellings, 
one  of  which  was  diagnosed  as  distended  gall-bladder  and 
the  other,  internal  to  the  gall-bladder,  as  a  pancreatic  cyst ; 
both  were  apparently  dependent  on  chronic  pancreatitis,  and 
were  drained  separately.  The  sequel  appeared  to  prove  that 
the  apparent  pancreatic  cyst  was  in  reality  an  enormously 
dilated  common  bile-duct,  as  after  operation  from  20  to 
30  ounces  of  bile  drained  from  it  daily,  whereas  only  clear 
mucus  came  from  the  gall-bladder.  The  pancreatic  fluid 
came  away  with  the  bile ;  the  nutrition  of  the  patient  could 
not  be  maintained  until  Benger's  liquor  pancreatici  was  given 
after  each  meal.  Choledochenterostomy  was  subsequently 
performed.     See  Cases  511  and  526.     The  patient  is  now  well. 

The  first  patient  was  a  man  of  twenty-five,  who  had 
suffered  severely  from  gall-stone  symptoms  associated  with 
a  tumour,  supposed  to  be  a  dilated  gall-bladder.  The  gall- 
bladder, however,  was  found  to  be  small,  and  situated  external 
to  the  cystic  tumour,  which  proved  to  be  a  dilated  cystic 
and  common  duct,  at  the  lower  end  of  which  was  a  gall- 
stone the  size  of  a  pigeon's  egg,  which  broke  into  fragments 
as  the  duct  was  about  to  be  incised  for  its  removal.  The 
fragments  were  removed  and  the  dilated  duct  was  opened 
and  stitched  to  the  aponeurosis  in  the  same  manner  as  one 
fixes  the  gall-bladder  in  cholecystotomy.     (Case  150.) 

The  second  case  was  a  woman  of  fifty-five,  from  whom  a 
very  thick  gall-bladder,  which  had  the  appearance  of  malig- 
nant disease,  was  removed  ;  the  cystic  duct  was  greatly 
dilated,  and  formed  part  of  the  tumour,  and  there  was  no 
difficulty  in  introducing  a  Murphy's  button  and  connecting 
it  to  the  intestine.     (Case  121.) 

Although  hitherto  the  results  of  choledochostomy  have 
not  always  been  favourable,  probably  in  consequence  of  the 
fact  that  extreme  distension  of  the  bile-duct  is  often  accom- 
panied by  infection  of  the  biliary  passages,  it  would  be  well 
to  reserve  our  opinion  as  to  the  prospects  of  the  operation 


198    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

until  we  have  more  experience  of  it.  Very  little  information 
can  as  yet  be  obtained  on  this  subject,  cases  of  extreme  dis- 
tension of  the  common  bile-duct  being  very  rare,  and  those 
in  which  surgery  has  intervened  still  more  exceptional. 

An  interesting  case  is  reported  by  Mr.  W.  P.  Swain,* 
in  which  he  connected  a  dilated  bile-duct  to  the  jejunum 
by  a  Murphy's  button.  The  size  of  the  tumour,  which 
occurred  in  a  girl  of  seventeen,  and  which  was  asso- 
ciated with  gall-stones,  may  be  gathered  from  the  fact  of 
over  7  pints  of  fluid  having  been  withdrawn  from  it  at 
the  time  of  operation.  Three  months  after,  the  patient  was 
progressing  satisfactorily,  except  for  an  occasional  rise  of 
temperature,  and  for  the  fact  that  the  button  had  not  been 
passed. 

Dr.  Russelrf  describes  a  case  in  a  boy,  aged  eight  years, 
whose  illness  began  with  an  attack  of  pain  in  the  right  side 
of  the  abdomen,  and  some  fever.  Jaundice  appeared  on  the 
second  day,  and  on  the  next  there  was  first  noticed  a  tumour. 
Associated  with  the  jaundice  there  were  the  usual  constipa- 
tion, clay-coloured,  offensive  stools,  and  bile-pigment  in  the 
urine.  By  the  fifth  day  there  was  a  large  tumour  continuous 
with  the  liver,  filling  the  right  lumbar  region,  extending  below 
the  anterior  superior  spine,  and  reaching  almost  to  the  middle 
line.  The  tumour  was  elastic,  dull  to  percussion,  and  some- 
what tender,  and  simulated  closely  a  hydatid  cyst  of  the  liver, 
for  which  it  was  mistaken.  In  the  right  semilunar  line,  just 
below  the  costal  margin,  was  a  smaller  rounded  tumour  which 
it  was  thought  might  be  due  to  a  distended  gall-bladder.  As 
it  was  believed  that  the  child  was  suffering  from  catarrhal 
jaundice  in  addition  to  hydatid  cyst  of  the  liver,  he  was  kept 
in  bed  for  sixteen  days.  During  this  period  no  bile  passed 
through  the  common  duct,  and  the  icterus  became  more 
profound.  At  the  end  of  this  time  he  began  to  suffer  from 
severe  gall-stone  colic  without  vomiting.  At  the  operation 
the  smaller  tumour  was  found  to  be  due  to  a  distended  gall- 
bladder full  of  colourless  mucus ;  the  larger  was  a  retro- 
peritoneal cyst,  from  which,  on  aspiration,  came  clear  fluid, 

*  Lancet,  March  23,  1895. 

f  Annals  of  Surgery,  December,  1897. 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE -DUCTS     199 

and  on  incision  some  black,  'cinder-like'  material  (bilirubin). 
After  operation,  bile  came  from  the  cyst,  which  was  stitched 
to  the  abdominal  parietes.  Death  took  place  on  the  fifth 
day  after  operation  from  haemorrhage.  At  the  post-mortem 
examination  the  retroperitoneal  tumour  was  found  to  be 
formed  by  an  immensely  dilated  common  duct,  the  orifice 
of  which  was  small  and  valvular.  Dr.  Russell  was  inclined 
to  believe  that  this  condition  was  congenital,  and  of  the  same 
nature  as  one  form  of  congenital  hydronephrosis.  So  long 
as  the  mucous  membrane  was  normal  at  the  orifice,  a  certain 
amount  of  bile  had  been  able  to  pass  into  the  intestine,  but 
immediately  the  catarrhal  condition  was  set  up  this  ceased 
to  be  possible.  As  a  consequence  the  duct  became  further 
dilated,  and  so  pressed  on  the  valvular  termination  of  the 
duct  as  to  quite  occlude  the  orifice. 

Dr.  Henry  Ashby  describes  another  case*  in  a  girl,  aged 
seven  years,  who  had  been  ill  for  two  and  a  half  years  with 
jaundice,  progressive  emaciation,  and,  latterly,  distension  of 
the  abdomen  and  oedema  of  the  feet.  After  50  ounces  of 
ascitic  fluid  had  been  removed  from  the  abdomen,  a  large 
cyst  was  found  occupying  mainly  the  right  side  of  the 
abdomen,  and  continuous  apparently  with  the  liver.  On 
aspiration,  16  pints  of  dark-green  mucus  were  removed  ; 
at  varying  intervals  during  the  following  three  months  the 
cyst  was  tapped  on  ten  occasions,  from  8  to  10  pints  of 
bile-stained  fluid  being  removed  each  time.  Under  this 
treatment  she  so  improved  that  it  was  considered  advisable 
to  drain  the  cyst.  This. was  done,  and  the  drainage  was 
continued  for  two  months,  during  which  time  the  whole  of 
the  bile  escaped  through  the  tube  inserted  into  the  cyst  after 
it  had  been  stitched  to  the  abdominal  wall.  As  a  result  of 
an  attempt  to  connect  the  cyst  with  the  bowel,  peritonitis  was 
set  up,  and  the  patient  succumbed.  At  the  autopsy  the  cyst 
was  found  to  be  firmly  attached  to  the  under  surface  of  the 
liver,  and  seemed  to  be  formed  by  enormous  distension  of  the 
common  and  cystic  ducts.  The  hepatic  duct  opened  into 
the  cavity,  but  there  was  no  communication  between  it  and 
the  duodenum. 

*  Medical  Chronicle,  October,  1898. 


200    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Specimen  No.  1,419,  Guy's  Museum,  shows  a  dilatation  of 
the  common  bile-duct.  There  is  a  thick-walled  cyst  6  inches 
across,  representing  the  common  bile-duct ;  the  portion  of 
duct  below  this  is  less  than  the  normal  calibre,  and  has  a 
valvular  fold,  which  completely  obstructs  the  lumen.  The 
tumour  was  aspirated  twice,  3  J  pints  of  bile  being  withdrawn 
on  each  occasion  without  relief.  Then  choledochostomy  was 
performed,  and  death  ensued  two  days  after  (Fig.  54). 

Dr.  Arnison  had  a  case  under  his  care  in  1891,  where  he 
operated  on  what  was  apparently  a  pancreatic  cyst,  which  he 
drained.  The  patient  was  extremely  ill  at  the  time,  and  only 
lived  a  few  days.  At  the  autopsy  the  operation  was  found  to 
have  been  a  choledochostomy,  and  the  tumour  to  have  been 
a  dilated  common  bile-duct. 

In  the  Hunterian  Museum  is  a  large  tumour  (Fig.  55)  of 
the  liver  constituted  by  dilated  hepatic  ducts,  which  form  a 
series  of  cysts  within  the  substance  of  the  liver  itself.  There 
was  no  obstruction  in  the  main  bile  channel. 

Solid  tumours  of  the  bile-ducts  may  be  simple  or  malignant. 

Simple  tumour  is  so  rare  that  the  following  case  (No.  234) 
is  worth  mentioning  more  fully  : 

During  the  twelve  months  before  coming  under  my  observa- 
tion the  patient,  a  woman,  aged  forty,  had  had  repeated 
attacks  of  what  appeared  to  be  appendicitis.  Each  attack 
began  by  acute  pain  in  the  right  iliac  region,  associated  with 
fever  and  vomiting,  and  followed  by  the  appearance  of  a 
tender  swelling  in  the  usual  situation  of  the  appendix,  and 
the  ordinary  symptoms  and  signs  of  a  localized  peritonitis  in 
that  region.  At  no  time  were  there  any  symptoms  to  suggest 
cholelithiasis. 

The  patient  was  seen  only  once,  after  one  of  these  seizures 
had  subsided,  and  the  diagnosis  of  relapsing  appendicitis, 
which  had  been  made  by  her  ordinary  medical  attendant,  was 
confirmed. 

At  the  operation  the  abdomen  was  opened  over  the  caecum, 
and  the  viscera  in  the  neighbourhood  were  found  all  matted 
together.  In  the  midst  of  these  adhesions  was  found  the 
gall-bladder,  situated  at  the  extremity  of  a  Riedel's  lobe,  and 
containing   muco-pus   and   several  gall-stones.     After  these 


PLATE  XXIV. 


Fig.  54. — Dilated  Common  Bile-duct  forming  a  Thick-walled  Cyst 
Six  Inches  in  Diameter. 

The  terminal  f  inch  of  the  duct  was  less  than  the  normal  calibre,  with  a 
valvular  fold  completely  obstructing  the  lumen.  It  was  twice  aspirated  of 
3^  pints  of  bile,  and  finally  choledochostomy  was  performed,  but  the 
patient  died  two  days  after. 

(No.  1,419,  Guy's  Museum.) 


To  face  p.  200. 1 


PLATE  XXV 


Fig.  55. — Cysts  in  Liver  formed  by  Dilated  Hepatic  Ducts. 
(No.  2,758c,  Royal  College  of  Surgeons  Museum.) 


To  face  p.  200.] 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     201 

had  been  removed  the  cystic  duct  was  found  to  be  the  seat 
of  a  tumour,  and,  as  this  gave  the  impression  of  a  new 
growth,  the  gall-bladder  and  its  duct,  along  with  the  project- 
ing lobe  of  the  liver,  were  removed  by  means  of  an  elastic 
ligature.  The  patient  made  an  uninterrupted  recovery,  and 
was  heard  of  in  1902  as  being  quite  well. 

The  tumour  was  examined  by  Mr.  Targett,  who  reported 
that  it  was  inflammatory  in  origin,  and  not  due  either  to 
tuberculous  disease  or  to  cancer. 

Drs.  Wilks  and  Moxon  (*  Pathological  Anatomy,'  p.  485) 
describe  what  appears  to  have  been  an  extreme  example  of  a 
duct  papilloma  in  a  child  of  four  years  of  age.  The  common 
bile-duct  was  dilated  so  as  to  form  a  cyst  as  large  as  a  child's 
head,  and  was  occupied  by  crowds  of  pedunculous  myxo- 
matous growths  containing  muscular  fibre. 

In  Dr.  Rolleston's  paper  a  case  is  referred  to  which  makes 
it  probable  that  an  adenoma  preceded  cancer.  Papilloma  is 
probably  an  earlier  stage  of  cancer,  and  is  rare. 

Sir  W.  H.  Bennett  removed  one  from  the  common  duct  of 
a  woman,  aged  fifty-eight,  in  St.  George's  Hospital,  the 
specimen  being  shown  at  the  Pathological  Society  of  London 
in  May,  1894.  The  growth  was  white  and  somewhat  granular 
to  the  naked  eye,  and  was  in  immediate  relation  with  an 
impacted  gall-stone.  The  papilloma  was  apparently  due  to 
the  irritation  of  the  calculus,  which,  judging  from  the  his- 
tory, had  been  impacted  for  twro  months. 

Of  the  malignant  tumours  wre  must  take  into  consideration 
the  two  classes,  sarcoma  and  cancer. 

Cancer  may  be  primary  or  secondary,  the  former  arising 
most  frequently  as  the  result  of  gall-stone  irritation,  the  latter 
by  extension  from  neighbouring  organs. 

Primary  malignant  disease  of  the  bile-duds  is  almost  in- 
variably, as  might  be  expected  from  their  histological  struc- 
ture, columnar-celled  carcinoma.  Musser  collected  eighteen 
cases,  and  found  all  of  them  to  be  formed  by  cylindrical- 
celled  carcinoma ;  while  out  of  other  sixteen  collected  by 
Rolleston,  fourteen  showed  similar  histological  characters, 
and  two  were  cases  of  encephaloid  cancer.  That  the  growth 
may  in  the  first  instance  be  a  papilloma,  subsequently  assum- 


202    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

ing  malignancy,  is  suggested  by  the  fact  that  the  tumour 
usually  projects  into  the  lumen  of  the  canal  as  a  villous-like 
mass,  while  at  the  same  time  the  submucous  tissue  is  infil- 
trated to  a  greater  or  less  extent. 

The  tumour  is  most  frequently  situated  in  the  common 
duct  towards  its  lower  end ;  but  the  cystic  or  hepatic  ducts 
may  be  first  affected.  In  Musser's  eighteen  cases  the  hepatic 
ducts  were  alone  involved  three  times,  the  cystic  and  hepatic 
ducts  once,  and  the  common  duct  fourteen  times.  Rolleston 
reports  seventeen  cases,  and  in  these  the  common  duct  alone 
was  the  seat  of  the  tumour  on  fifteen  occasions  (the  lower 
end  of  the  duct  being  involved  ten  times),  and  the  cystic 
duct  twice ;  but  in  one  of  the  latter  cases  there  was  also  an 
apparently  distinct  growth  at  the  lower  end  of  the  common 
duct. 

As  is  the  case  in  malignant  disease  of  the  gall-bladder,  so 
here,  systemic  infection  is  rare ;  but,  by  extension,  the  growth 
may  infiltrate  the  neighbouring  structures,  the  liver  being 
most  frequently  involved.  The  lymphatic  glands  in  the 
gastro-hepatic  omentum  are,  of  course,  involved  sooner  or 
later  in  all  cases. 

Dr.  Rolleston  draws  attention  to  the  fact  that,  out  of  the 
thirty-six  cases  collected,  gall-stones  were  present  only  in 
half  the  number.  He  thinks  that  calculi  are  less  frequently 
associated  with  primary  cancer  of  the  bile-ducts  than  with 
cancer  of  the  gall-bladder.  The  same  arguments  apply, 
however,  as  in  cancer  of  the  gall-bladder,  where  the  matter 
is  fully  discussed.  In  all  probability  the  carcinoma  is 
usually  secondary  to  gall-stones,  though  these  may  not 
always  be  found,  having  passed  into  the  bowel  before  the 
operation. 

These  growths  are  usually  found  between  the  ages  of  fifty 
and  sixty,  and,  unlike  cancer  of  the  gall-bladder,  where 
rather  more  than  75  per  cent,  of  the  cases  occur  in  women, 
the  disease  attacks  both  sexes  about  equally.  Out  of  thirty- 
six  cases,  twenty-one  occurred  in  males  and  fifteen  in 
females. 

Secondary  carcinoma  may  occur  from  extension  of  malig- 
nant disease  into  the  bile-ducts.     Thus,  one  may  find  cancer 


TUMOURS  OF  THE  GALL-BLADDER  AND  DILEDUCTS     203 

of  the  bile-ducts  supervening  on  cancer  beginning  in  the 
liver,  gnll-bladder,  pancreas,  or  intestine. 

Symptoms. — If  forming  in  the  cystic  duct,  jaundice  will  be 
absent  at  first,  only  coming  on  when  the  growth  advances  so 
far  as  to  press  on  the  common  duct  and  obstruct  the  passage 
of  the  bile,  or  when,  as  is  not  uncommon,  catarrh  of  the 
bile-ducts  supervenes.  The  gall-bladder  enlarges  at  an  early 
stage,  and  this  will  probably  be  the  earliest  sign;  pain  may 
be  absent,  unless  gall-stones  exist,  when  the  usual  spasmodic 
pains  will  occur  so  long  as  the  muscular  coat  of  the  gall- 
bladder retains  its  contractile  power. 

When  the  growth  is  in  the  common  duct,  jaundice  comes 
on  at  an  early  stage,  and  persists  throughout,  the  liver 
gradually  increasing  in  size,  and  the  gall-bladder  also  en- 
larging ultimately ;  in  the  later  stages,  the  changes  in  the 
character  of  the  blood  bring  about  a  condition  rendering 
the  subject  prone  to  haemorrhages  from  the  nose,  bowel,  etc., 
to  a  petechial  eruption  in  the  skin,  and  to  a  tendency  to 
bleed  from  wounds,  thus  rendering  operation  extremely 
hazardous. 

Associated  with  the  absence  of  bile  from  the  intestine 
there  are  usually,  to  a  greater  or  less  extent,  gastro-intestinal 
symptoms,  especially  constipation  or  constipation  alternating 
with  diarrhoea. 

Sometimes  paroxysmal  attacks  of  pain  resembling  that 
due  to  gall-stones  are  met  with  either  before  or  after  the 
development  of  jaundice,  and  may  be  due  to  associated 
calculi.  Similar  attacks  of  pain  may  be  met  with  in  carci- 
noma of  the  head  of  the  pancreas  or  in  growth  involving 
the  portal  fissure. 

The  gall-bladder  becomes  distended  and  is  palpable  in 
a  number  of  cases.  Enlargement  of  the  liver  is  slight, 
and  secondary  growths  are  comparatively  seldom  felt  during 
life. 

As  biliary  toxaemia  appears,  the  symptoms  are  aggravated, 
ascites  and  oedema  may  appear,  and  the  condition  of  extreme 
depression  may  terminate  in  exhaustion,  coma,  or  delirium. 

Suppurative  cholangitis  is  apt  to  supervene,  the  case  then 
taking  on  a  more  acute  course,  and  being  accompanied  by 


204    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

fever,  ague-like  attacks,  and  rapid  loss  of  flesh  and  strength. 
If  the  tumour  form  in  the  hepatic  duct,  jaundice  will  be  the 
earliest  symptom,  and  the  case  will  resemble  one  of  obstruc- 
tion in  the  common  duct,  with  the  exception  of  an  absence 
of  enlargement  of  the  gall-bladder.  Needless  to  say,  the 
disease  is  uniformly  fatal,  though  operation  may  delay  the 
final  catastrophe. 

Case  276,  seen  with  Dr.  Wardrop  Griffith,  is  a  good  illus- 
tration of  cancer  of  the  ducts,  and  it  shows  also  very  well  the 
usual  history  of  gall-stone  colic  for  a  long  period  prior  to  the 
beginning  of  the  malignant  disease. 

The  patient,  who  was  a  woman,  aged  sixty-eight,  gave  a 
history  of  attacks  of  well-marked  biliary  colic  since  child- 
hood. These  seizures  at  first  occurred  about  twice  in  the 
year;  but  latterly  they  had  become  much  more  frequent, 
and  during  the  last  year  recurred  about  once  a  month. 

The  illness  for  which  she  sought  treatment  at  the  Leeds 
Infirmary  began  in  April,  1899,  like  an  ordinary  gall-stone 
colic;  but  the  jaundice,  which  was  first  noticed  a  week  after 
the  onset  of  pain,  persisted,  and  got  gradually  more  marked. 
Thence  till  her  admission  to  hospital  in  July  she  had  no 
recurrence  of  severe  pain  ;  but  there  had  been  occasional 
shooting  pains  in  the  upper  abdomen,  and  constant  tender- 
ness in  the  region  of  the  gall-bladder.  She  lost  rapidly  in 
strength  and  weight,  and  in  July  was  21  pounds  lighter  than 
she  had  been  at  the  beginning  of  the  year. 

As  medical  treatment,  persisted  in  for  two  and  a  half 
weeks,  failed  to  give  any  relief,  it  was  decided  to  have  her 
transferred  to  the  surgical  side  for  operation. 

When  seen  she  was  so  ill  that  it  was  not  considered  safe 
to  employ  a  general  anaesthetic,  especially  as  it  was  almost 
certain  she  was  now  the  subject  of  malignant  disease  as  well 
as  gall-stones. 

The  operation  was  done  on  July  20,  cocaine  being  the 
only  anaesthetic  used.  The  gall-bladder  was  aspirated,  in- 
cised, and  stitched  to  the  parietes  in  the  usual  way,  no 
attempt  being  made,  on  account  of  the  weak  condition  of 
the  patient,  to  exactly  localize  the  obstruction. 

Notwithstanding  the  apparent  simplicity  of  the  operation, 


PLATE  XXVI 


Fig.    56. — Tumour    occupying    the    Junction    of    Hepatic,    Cystic,    and 
Common  Ducts,  and  completely  occluding  them. 

(From  drawing  by  Dr.  Robert.) 

The  hepatic  ducts  have  been  cut,  and  are  turned  forward. 


Fig.  57. -Cancer  of  Ampulla. 

(After  drawing  in  Trans.  Path,  and  Clin.  Sac.,  Glas.) 

Parts  shown  by  dividing  the  duct  on  into  the  duodenum  :  a,  terminal  part  of 
duct,  with  tumour,  h,  c,  duodenum  laid  open;  d,  pylorus;  c,  stomach; 
/,  liver  (shaded  dark)  ,  g,  collapsed  gall-bladder  ;  //,  probe  passed  from 
gall-bladder  through  aperture,  and  emerging  in  the  midst  of  adherent 
omentum  ;  i,  suspensory  ligament. 

To  face  p.  205.") 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE -DUCTS     205 

and  the  absence  of  visceral  exposure,  there  followed  a  con- 
siderable amount  of  shock. 

There  were  haematemesis  and  some  little  haemorrhage 
from  the  wound  on  the  21st  and  22nd,  and  notwithstanding 
stimulation  and  other  general  treatment  the  patient  gradually 
sank,  dying  from  exhaustion  on  the  24th. 

At  the  autopsy,  besides  extensive  heart  disease  and  granular 
kidneys,  there  were  found  two  large  stones,  one  in  the  gall- 
bladder, the  other  impacted  in  the  cystic  duct.  Situated  at 
the  junction  of  the  cystic,  hepatic,  and  common  bile-ducts 
was  a  growth  about  the  size  of  a  filbert,  which  was  found, 
when  the  ducts  were  opened,  to  completely  occlude  them 
(see  Fig.  56). 

There  were  no  adhesions  in  the  neighbourhood,  nor  were 
there  any  secondary  growths  to  be  found.  The  stomach 
showed  no  evidences  of  ulceration,  but  there  were  slight 
signs  of  cirrhosis  of  the  liver.     There  was  no  peritonitis. 

Cancer  of  the  Ampulla  of  Vater. — This  condition  was 
probably  first  described  by  McNeal  in  1835  (m  the  North 
A  merican  A  rchiv.,  Baltimore),  and  was  later  drawn  attention  to 
by  Stokes  in  1846  (Dublin  Quarterly  Journal  of  Medical  Science, 
1846).  More  recently  the  subject  has  been  fully  dealt  with 
by  M.  Hanot  (Archives  Generates  de  Medecine,  November, 
1896),  M.  Durand-Fardel  (La  Presse  Medicate,  1896),  M.  Rendu 
and  Dr.  Rolleston  (Medical  Chronicle,  1895,  and  Lancet,  Feb- 
ruary 16,  1901).  Rolleston  (Lancet,  February  16,  1901),  in  a 
most  instructive  paper  on  the  subject  of  carcinoma  of  the 
ampulla  of  Vater,  draws  attention  to  the  varieties  of  malig- 
nant growth  which  may  be  met  with  in  this  region. 

The  growth  may  arise  in  the  mucous  membrane  covering 
the  duodenal  surface  of  the  biliary  papilla,  in  the  mucous 
membrane  of  the  ampulla  of  Vater,  at  the  termination  of 
the  common  bile-duct,  and  at  the  termination  of  Wirsung's 
duct.  The  accompanying  diagram  illustrates  these  distinc- 
tions. 

Confusion  may  also  arise  between  carcinoma  of  the  head 
of  the  pancreas  and  primary  carcinoma  of  the  ampulla 
Vateri.  Carcinoma  of  the  pancreas,  however,  is  spheroidal- 
celled,  while  carcinoma  of  the  ampulla  of  Vater  is  columnar- 


2o6    DISEASES  OE  THE  GALL-BLADDER  AND  BILE-DUCTS 

celled.  Growth  may  also  extend  to  the  ampulla  of  Vater 
from  the  termination  of  the  common  bile-duct,  or  from 
Wirsung's  duct.  In  coming  to  a  decision  as  to  the  seat  of 
origin  of  the  growth  in  such  cases,  it  may  be  pointed  out 
that  carcinoma  of  the  ampulla  of  Vater  may,  when  of  con- 
siderable size,  project  as  a  tumour  through  the  gaping  lips 
of  the  biliary  papilla,  and  be  visible  in  the  duodenum.  This 
is  not  seen  in  cases  of  carcinoma  of  the  pancreas  or  of  the 
termination  of  the  common  bile-duct. 

The  clinical  characters  of  biliary  carcinoma  of  the  ampulla 
of  Vater  are  the  same  as  those  of  primary  carcinoma  of  the 
common  bile-duct — viz.,  progressive  jaundice  and  wasting, 
the  patient  finally  passing  into  a  condition  of  cholaemia  or 
biliary  toxaemia.  It  thus  very  closely  resembles  cases  of 
carcinoma  of  the  head  of  the  pancreas,  the  only  difference 
being  that  jaundice  is,  exceptionally,  absent  in  the  latter 
condition. 

Rolleston  considers  that  of  the  twenty-one  recorded  cases 
of  carcinoma  of  the  ampulla  of  Vater  which  he  was  able  to 
collect,  seven  were  genuine  examples  of  this  condition  ;  the 
remainder  were  either  carcinoma  of  the  termination  of  the 
common  bile-duct  or  of  the  duodenal  surface  of  the  biliary 
papilla.     He  reports  the  following  case  : 

Carcinoma  of  the  Ampulla  Vateri — Dilated  Common  Bile  and 
Wirsung  s  Ducts — Death  from  Haemorrhage  into  the  Dilated  Duct 
of  Wirsung. — A  man,  aged  sixty-six  years,  was  admitted  into 
St.  George's  Hospital  under  my  care  on  July  22,  1900,  with 
jaundice,  pruritus,  weakness,  and  wasting.  Ten  weeks  pre- 
viously he  had  considered  himself  quite  well ;  jaundice  then 
appeared  quite  painlessly,  and  a  month  later  he  got  weaker 
and  felt  drowsy  ;  six  weeks  after  the  onset  of  jaundice  the 
skin  began  to  itch.  There  was  no  history  of  gall-stones. 
When  examined  on  admission  he  was  deeply  jaundiced,  and 
the  skin  showed  the  effects  of  scratching ;  the  liver  was  en- 
larged, reaching  to  the  fourth  rib  above,  and  extending  two 
and  a  half  finger-breadths  below  the  costal  arch  in  the  right 
nipple  line  ;  the  surface  was  smooth,  and  the  gall-bladder 
could  be  indistinctly  felt.  No  splenic  enlargement  could  be 
made  out.    There  was  some  abdominal  distension  and  tender- 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS     207 

ness  at  a  spot  over  the  eleventh  and  twelfth  ribs  in  the  right 
hypochondrium,  but  no  ascites.  Per  rectum  nothing  but  an 
hypertrophied  prostate  could  be  felt.  The  urine  contained 
albumin  and  bile,  but  no  sugar.  The  patient  had  been  sent 
to  the  hospital  as  a  case  of  cancer  of  the  liver.  It  appeared 
probable,  however,  that  the  growth  was  in  the  head  of  the 
pancreas.  On  July  25  there  was  some  diarrhcea  ;  on  July  26 
he  vomited,  had  a  rigor,  and  the  temperature  fell  to  960  F.  ; 
the  pulse  was  small,  and  he  was  collapsed.  The  abdomen 
moved  well,  and  it  appeared  unlikely  that  perforation  of  the 
gall-bladder  from  overdistension,  as  in  a  case  recorded  by 
Coats  and  Finlayson  (Transactions  Path,  and  Clin.  Soc,  Glas., 
vol.  cxi.),  had  occurred.  Suppuration  around  the  gall-bladder 
was  thought  of,  but  his  condition  precluded  any  surgical 
treatment,  and  he  was  given  morphia.  Death  occurred 
eighteen  hours  after  the  onset  of  acute  symptoms. 

At  the  necropsy,  performed  by  Dr.  W.  J.  Fenton,  the 
peritoneal  cavity  showed  no  recent  peritonitis,  but  con- 
tained two  pints  of  bile-stained  fluid.  A  flat  growth  was 
found  limited  to  the  ampulla  of  Vater,  and  occluding  the 
orifices  of  both  the  common  bile-duct  and  the  duct  of 
Wirsung.  This  growth  was  not  visible  from  the  duodenum, 
and  was  only  seen  when  the  papilla  was  opened  up. 
Microscopically,  the  growth  was  a  columnar-celled  carcinoma, 
and  was  found  to  be  invading  the  smooth  muscular  tissue 
around  the  ampulla  Vateri.  The  common  bile-duct  was 
greatly  dilated  with  dark  bile,  and  was  as  thick  as  one's  thumb. 
When  the  finger  was  introduced  into  the  duct  and  directed 
downwards  towards  the  biliary  papilla,  the  common  duct  was 
felt  to  end  blindly  like  a  test-tube.  The  hepatic  and  cystic 
ducts,  and  the  gall-bladder  were  greatly  dilated.  No  gall- 
stones were  found.  The  liver  weighed  4  pounds.  It  was 
enlarged,  smooth  on  the  surface,  and  deeply  bile-stained. 
Microscopically,  there  was  no  cirrhosis,  though  the  atrophied 
and  degenerated  condition  of  the  liver  cells  allowed  the  exist- 
ing fibrous  tissue  of  the  portal  spaces  to  appear  more  promi- 
nent than  in  health.  Wirsung's  duct  was  tortuous  and  dilated 
throughout  the  whole  of  the  pancreas.  In  the  head  of  the 
gland  there  was  a  large  cystic  dilatation  of  the  duct  which 


208    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

contained  recent  blood-clot  ;  the  rest  of  the  dilated  duct 
contained  dark  brown  fluid.  No  calculi  were  seen.  The 
tail  of  the  pancreas  was  adherent  to  the  stomach  by  old 
adhesions,  evidently  the  result  of  past  inflammation.  To 
the  naked  eye  the  pancreas  was  extremely  fibrotic.  Micro- 
scopically, the  glandular  tissue  of  the  organ  was  widely 
replaced  by  fibrous  tissue,  and,  where  it  could  be  made  out, 
was  much  disorganized.  Numerous  dilated  ducts  were  seen, 
some  of  which  contained  microscopic  calculi.  There  was 
some  recent  small-cell  infiltration.  The  stomach  and  intes- 
tines showed  signs  of  recent  catarrhal  inflammation.  The 
kidneys  presented  senile  changes  and  a  few  cysts.  No 
secondary  growths  were  found  in  any  part  of  the  body. 

Dr.  Haviland  Hall  (Lancet,  April  19,  1902)  reports  the 
following  case  of  primary  carcinoma  of  the  ampulla  of  Vater. 

'  The  patient,  a  man,  aged  forty-six,  was  first  seen  on 
October  6,  1900.  He  stated  that  he  had  been  quite  well 
until  the  preceding  August  ;  then  he  had  a  febrile  attack 
(the  temperature  was  from  1030  to  1040  F.  for  two  days), 
accompanied  with  pain  in  the  head  and  limbs.  The  attack 
closely  resembled  influenza.  After  three  or  four  days  the 
temperature  became  normal,  and  the  patient  suffered  from 
itching  and  flatulence.  About  a  week  later  he  became 
jaundiced  and  felt  ill,  but  there  was  no  vomiting,  diarrhoea, 
or  pain.  This  condition  continued  up  to  the  time  that 
I  first  saw  him.  On  examination,  the  thoracic  viscera  were 
found  to  be  normal.  The  liver  was  uniformly  and  greatly 
enlarged,  reaching  nearly  to  the  umbilicus,  and  the  distended 
gall-bladder  could  be  made  out.  The  motions  were  clay- 
coloured  and  the  urine  was  bile-stained.  The  temperature 
was  normal.  The  patient  had  lost  about  2  stones  in  weight 
since  the  commencement  of  his  illness.  Previously  to  the 
present  illness  the  patient's  health  had  been  excellent  ;  there 
was  no  history  of  enteric  fever,  pneumonia,  or  any  other 
serious  affection.  He  was  ordered  chloride  of  ammonium 
(20  grains)  every  six  hours. 

1 1  did  not  see  the  patient  again  until  he  was  admitted  into 
the  Westminster  Hospital  under  my  care  on  January  5,  1901. 
On  admission  he  was  deeply  jaundiced.     The  liver  could  be 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS    209 

felt  three  or  four  fingers'  breadth  below  the  costal  margin  ; 
it  was  hard  and  rather  tender,  and  it  appeared  to  be 
regularly  enlarged.  The  gall-bladder  was  distended.  The 
spleen  could  not  be  felt.  There  was  no  ascites  and  no 
oedema.  The  stools  were  semi-solid,  clay-coloured,  and  very 
offensive.  The  urine  was  acid,  bile-stained,  and  free  from 
albumin  and  sugar.  The  temperature  on  admission  was 
980  F.  On  the  7th  it  rose  to  102*4°  F.,  falling  the  next  day  to 
97  6°,  but  there  was  another  rise  on  the  9th  to  104°  F.  The 
patient  became  comatose  at  4  p.m.  on  the  9th,  having  pre- 
viously complained  of  severe  headache  for  some  hours.  On 
the  10th  the  temperature  gradually  and  steadily  rose,  and  at 
5  a.m.  on  the  nth  it  was  107°  F.,  and  the  patient  died. 

•  On  post-mortem  examination  the  liver  weighed  7  pounds  ; 
it  was  enlarged  and  of  a  deep  green,  almost  black,  colour. 
Its  substance  was  fairly  firm.  The  bile  passages  were 
much  dilated  throughout  the  organ.  The  gall-bladder  was 
dilated  and  full  of  pale  green  bile  of  a  watery  consis- 
tence. The  cystic  duct  was  much  dilated,  and  the  common 
bile-duct  was  sufficiently  large  to  admit  the  little  finger  in 
its  main  course.  At  the  papilla  in  the  duodenum  the  orifice 
was  of  the  normal  size,  but  the  whole  papillae  and  a  small 
portion  of  the  duct  behind  the  opening  were  enlarged  and 
firm,  so  that  a  mass  of  the  size  and  somewhat  of  the  shape 
of  a  small  bean  lay  beneath  the  duodenal  mucous  membrane. 
The  pancreatic  duct  was  much  dilated,  and  bile  could  be 
made  to  flow  through  the  unopened  papilla  by  pressure  on 
the  gall-bladder.  On  slitting  up  the  common  duct  from  the 
papilla  it  was  seen  that  there  was  a  soft  and  ulcerating  mass 
of  material  lying  immediately  within  the  orifice.  From  the 
surface  of  this  a  fluid  having  the  appearance  of  pus  could 
be  scraped.  The  mass  surrounded  the  entire  lumen,  but  did 
not  extend  further  along  the  duct  than  about  J  inch,  and  it 
did  not  invade  deeper  tissues.  The  tail  of  the  pancreas 
was  very  dense,  but  the  head  was  of  normal  consistency. 
Wirsung's  duct  was  dilated  throughout.  No  ascites  was 
found  in  the  abdomen.  Microscopically,  the  growth  was  a 
columnar-celled  carcinoma.' 

A  typical  case,  ending  in  rupture  of  the  gall-bladder  and 

?4 


210    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

general  peritonitis,  is  described  by  Dr.  Coats  and  Dr. 
Finlayson,  and  the  parts  figured*  in  the  Transactions  of  the 
Pathological  and  Clinical  Society  of  Glasgow  (see  Fig.  57). 

Diagnosis. — The  diagnosis  of  a  primary  growth  of  the  bile- 
passages  is  frequently  a  matter  of  the  greatest  difficulty. 
Even  in  cases  in  which  one  can  definitely  say  that  the 
symptoms  are  not  due  to  impaction  of  calculi  in  the  ducts, 
it  will  be  impossible  to  exclude  malignant  disease  in 
adjacent  organs,  such  as  the  head  of  the  pancreas  or  the 
duodenum.  The  chief  symptoms  commonly  found  in  cancer 
of  the  head  of  the  pancreas  are  those  of  cancer  of  the 
common  bile-duct,  and  also  of  the  ampulla  of  Vater — viz., 
progressive  emaciation  and  jaundice,  with  enlargement  of 
the  gall-bladder.  Impaction  of  a  gall-stone  in  the  common 
duct  is  usually  indicated  by  a  distinct  history  of  biliary  colic 
immediately  preceding  the  onset  of  jaundice.  Where,  how- 
ever, the  cystic  and  common  ducts  are  dilated  as  a  result 
of  the  previous  passage  of  gall-stones,  impaction  of  a  calculus 
may  occur  without  any  great  pain.  On  the  other  hand, 
obstruction  due  to  malignant  disease  may  be  accompanied 
by  attacks  of  pain  resembling  biliary  colic. 

The  distension  of  the  gall-bladder  which  is  supposed  to 
be  the  rule  in  obstructive  jaundice  other  than  that  due  to 
gall-stones  may  be  absent,  owing  to  contraction  of  the  gall- 
bladder following  previous  cholelithiasis. 

As  time  goes  on  and  the  case  progresses  it  become  obvious 
that  the  cause  of  the  jaundice  is  malignant  disease,  but  in 
the  early  stages  it  is  absolutely  impossible,  in  the  majority 
of  cases,  to  make  a  certain  diagnosis.  The  difficulty  can 
only  be  cleared  up  by  an  exploratory  operation,  which 
should  be  performed  at  an  early  period.  If  gall-stones  are 
present  they  can  be  removed,  and  if  the  condition  is  due  to 
malignant  disease  it  may  be  possible  to  remove  the  growth, 
or,  if  this  be  impracticable,  to  perform  cholecystenterostomy. 

Cystic  dilatation  of  the  bile-ducts  is  often  indistinguishable 
from  enlargement  of  the  gall-bladder,  as  in  Terrier's  third 
and  in  my  own  first  case,  for  which,  indeed,  it  is  usually 
mistaken  ;    but  it  may  resemble  a  cyst  of  the  pancreas,  as 

*  Transactions  of  Pathological  an4  Clinical  Society,  Glasgow,  vol.  iii, 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE -DUCTS    211 

in  Dr.  Arnison's  case,  in  M.  Terrier's  first  case,  and  in  my 
case  (No.  511),  or  a  hydatid  tumour  of  the  liver,  as  in  Terrier's 
second  case,  and  in  Dr.  Russell's  patient.  But,  as  the  treat- 
ment in  all  these  conditions  is  abdominal  section,  no  harm 
will  be  done  if  the  diagnosis  is  only  completed  when  the 
abdomen  is  opened. 

Treatment. — The  operative  treatment  of  these  tumours  is  in 
its  infancy.  If  the  cause  be  a  removable  one,  such  as  a  gall- 
stone, it  should  be  taken  away.  Choledochostomy  has  not 
yielded  good  results  in  cystic  dilatation  of  the  bile-ducts, 
my  own  cases  being,  I  believe,  the  only  examples  of  com- 
plete recovery  after  the  operation,  whereas  the  experience 
of  performing  an  anastomosis  between  the  cyst  and  the 
intestine,  though  as  yet  slight,  has  been  so  satisfactory  as  to 
establish  the  claim  to  its  being  considered  the  best  method 
of  treatment. 

In  malignant  disease  an  accurate  diagnosis  can  often  only 
be  made  after  the  abdomen  is  open.  In  some  cases  the 
condition  of  the  patient  or  the  extent  of  the  growth  may 
only  permit  a  palliative  operation.  In  such  a  case,  the 
dilated  gall-bladder  or  ducts  may  be  opened  and  drained 
or  short-circuited  into  the  duodenum  or  colon.  In  two  cases 
only  has  removal  of  such  a  growth  been  performed,  by 
W.  S.  Halstead  (Boston  Medical  and  Surgical  Journal,  Decem- 
ber 28,  1899)  and  by  W.  J.  Mayo  (St.  Paul's  Medical  Journal, 
June,  1901).  As  these  cases  illustrate  the  various  operative 
procedures  that  may  be  necessary,  they  are  given  in  some 
detail. 

Halstead's  patient  was  a  woman,  aged  sixty.  Her  illness 
commenced  with  itching  of  the  skin,  which  came  on  sud- 
denly, and  soon  became  severe.  The  patient  said  that  the 
jaundice  did  not  appear  for  nearly  a  month  after  the  onset 
of  the  itching.  There  were  no  chills,  no  fever,  and  no 
sweating.  Following  the  extraction  of  a  tooth  she  had  per- 
sistent bleeding  of  the  gums,  and  at  times  the  haemorrhage 
was  profuse.  Five  months  before  the  onset  of  the  itching 
she  had  attacks  of  severe  pain  in  the  epigastrium,  unaccom- 
panied by  vomiting,  fever,  or  sweating.  The  stools  were 
light  in  colour  for  two  or  three  days  at  the  beginning  of  the 

14 — 2 


212    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

attacks,  but  there  was  no  jaundice  noticed.  On  examination 
the  liver  was  enlarged  and  the  gall-bladder  greatly  dilated. 

Operation,  February  14,  1898. — The  gall-bladder,  common 
and  cystic  ducts,  were  much  dilated.  The  gall-bladder  was 
incised  and  clear  fluid  with  some  miniature  gall-stones 
removed.  The  common  duct  was  explored  through  an 
incision,  and  what  seemed  to  be  a  small,  hard  stone  felt  at 
the  ampulla  of  Vater.  The  duodenum  was  incised  and  the 
mass  was  found  to  be  a  carcinoma. 

A  wedge-shaped  piece  of  the  duodenum  with  the  apex 
at  the  mesenteric  border  was  incised  with  about  f  inch 
of  the  common  duct  and  a  shorter  piece  of  the  pancreatic 
duct.  An  end  to  end  anastomosis  of  the  duodenum  was 
then  made,  the  common  and  pancreatic  ducts  being  trans- 
planted into  the  duodenum  along  the  line  of  suture.  The 
linear  incision  in  the  common  duct  was  sutured  and  the 
gall-bladder  drained,  a  gauze  drain  also  being  passed  down 
to  the  sutured  intestine.  The  patient  recovered  from  the 
operation,  and  ten  weeks  later  cholecystenterostomy  was 
performed,  no  recurrence  being  found  at  the  second  opera- 
tion.    She  died,  however,  from  recurrence  six  months  later. 

W.  J.  Mayo's  patient  was  a  woman,  aged  fifty-nine,  who 
had  suffered  for  many  years  from  biliary  colic.  For  twelve 
months  the  patient  had  been  losing  weight  (40  pounds  in 
all).  She  was  somewhat  emaciated,  and  there  was  marked 
cachexia  and  moderate  jaundice.  The  liver  was  enlarged, 
but  the  gall-bladder  could  not  be  felt. 

Operation,  November  3,  1900. — A  single  non-faceted  stone 
was  removed  from  the  gall-bladder.  No  stone  could  be  felt 
in  the  ducts.     Gall-bladder  drained. 

For  forty-eight  hours  drainage  of  bile  was  free,  but 
gradually  increased  in  quantity  up  to  2  or  more  pints  a 
day ;  the  skin  became  greatly  irritated  from  the  discharge, 
and  examination  showed  that  a  large  part,  if  not  all,  of  the 
pancreatic  secretion  was  being  discharged  with  all  of  the 
bile.  The  jaundice  disappeared,  but,  the  discharge  of  bile 
continuing,  the  abdomen  was  reopened  on  January  31,  1901. 
At  the  extreme  end  of  the  common  duct  a  hard  body  could 
be  felt  through  the  wall  of  the  duodenum,  which  was  sup- 


TUMOURS  OF  THE  GALL-BLADDER  AND  BILE-DUCTS    213 

posed  to  be  a  calculus.  An  incision  was  made,  2  inches  in 
length,  in  the  anterior  wall  of  the  duodenum,  exposing  a 
grayish-white  mass  which  was  strictly  localized  to  the  site 
of  the  papilla  of  the  common  duct.  Its  size  did  not  exceed 
the  end  phalanx  of  the  forefinger  ;  about  one-third  of  its 
length  projected  into  the  lumen  of  the  duodenum,  and  two- 
thirds  posterior  to  the  intestinal  wall.  The  tumour  was 
excised,  exposing  the  free  end  of  the  common  duct.  The 
removal  was  made  partly  with  the  knife  and  partly  with  the 
cautery,  and  finally  the  whole  surface  was  seared  with  the 
cautery.  The  duodenal  incision  was  sutured,  a  small  gauze 
drain  inserted,  and  the  wound  closed,  the  gall-bladder  fistula 
being  undisturbed.  The  discharge  from  the  fistula  ceased 
in  three  weeks,  the  stools  became  normal  in  appearance,  and 
the  gain  in  weight  and  general  appearance  was  most  rapid. 

Microscopic  examination  showed  the  growth  to  be  a 
cylindrical-celled  carcinoma. 

The  following  case  was  under  my  care  in  the  Leeds 
General  Infirmary,  but  it  scarcely  comes  under  the  same 
category  as  the  cases  related,  since  the  disease  had  extended 
to  the  neighbouring  organs. 

Case  536. — M.  T.,  aged  thirty,  sent  by  Dr.  Pritchard, 
Dewsbury.  Three  years  ago  the  patient  had  an  illness 
characterized  by  abdominal  pain  and  jaundice,  lasting  for 
three  or  four  weeks.  The  jaundice  passed  off,  but  three 
months  afterwards  the  attack  of  pain  was  repeated,  but  not 
followed  by  jaundice.  Since  then  he  had  had  several  attacks, 
but  no  further  jaundice.  The  pain  was  in  the  right  hypo- 
chondriac region,  passing  below  the  right  shoulder  blade  ; 
he  had  lost  a  stone  in  weight.  When  seen  by  me  the 
patient  was  very  slightly  jaundiced;  the  stomach  was 
markedly  dilated ;  there  wras  no  tenderness,  but  an  indefinite 
swelling  was  felt  above  and  to  the  right  of  the  umbilicus. 

Operation,  April  18,  1901. — The  growth  was  found  involv- 
ing the  inner  part  of  the  duodenum,  from  which  it  had 
extended  to  the  pylorus  and  head  of  the  pancreas.  While 
separating  adhesions  a  perforation  of  the  duodenum  was  dis- 
covered, and  as  this  could  not  be  safely  closed  by  sutures, 
an   attempt    was    made    to    remove    the    disease.      It    had 


2T4    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

evidently  started  in  the  region  of  the  papilla,  and  to  effect 
its  removal  it  was  necessary  to  excise  a  portion  of  the  inner 
wall  of  the  duodenum.  As  the  pylorus,  and  part  of  the  head 
of  the  pancreas  were  involved  in  the  disease  an  extension  of 
the  operation  was  called  for,  the  bloodvessels  being  tied 
as  they  were  divided.  The  walls  of  the  duodenum  and 
stomach  were  brought  together  by  sutures,  and  as  it  was 
clear  that  the  common  duct  would  be  obstructed,  the  gall- 
bladder was  drained,  with  a  view  to  cholecystenterostomy 
at  a  later  date  if  the  patient  recovered.  The  patient  suffered 
considerably  from  shock  after  the  operation,  and  though  he 
rallied  at  first,  he  died  a  few  days  later  from  exhaustion. 


PLATE  XXVII. 


•*«* 


*jii&* 


Fig.  58. — One  Hundred  and  Forty-five  Gall-stones,  Actual  Size, 

REMOVED    BY    ChOLECYSTOTOMY. 

(Case  455.) 


To  face  p.  215.] 


A. — From  Case  i. 


B. — From  Case  g. 


C. — From  Case  27. 
1  -k.    59.     Examples  ok  Call-stones. 


To  face  p.  215.  | 


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•2 


CHAPTER  VII 

GALL-STONES,  OR  CHOLELITHIASIS 

The  importance  of  this  subject  may  be  gathered  from  the 
facts  that  post-mortem  records  on  persons  of  all  ages  and 
both  sexes  prove  gall-stones  to  be  present  in  from  5  to  10 
per  cent,  of  all  Europeans ;  in  Strasburg  the  record  being 
12  per  cent.  (Schroeder),  in  Kiel  5  per  cent.,  and  in 
Manchester  4-4  per  cent.  (Brockbank). 

Pathology  and  Etiology. — Gall-stones,  which  when  small 
are  often  spoken  of  as  biliary  sand,  may  vary  in  size  from  a 
concretion  just  perceptible  to  the  naked  eye  (Fig.  58)  up 
to  a  mass  the  size  of  a  tennis-ball,  or  even  larger  (Fig.  59). 

The  following  description  and  illustration  (Fig.  60)  of  the 
largest  gall-stone  that  has,  so  far  as  we  know,  been  described 
are  taken  from  Mr.  Hutchinson's  Archives  of  Surgery  for  July, 
1891,  the  original  source  being  Dr.  Spen's  translation  of 
Dr.  Aug.  G.  Richter's  work,  entitled  '  Medical  and  Surgical 
Observations,'  published  in  1793. 

Enormous  Gall-stones  removed  after  Death. — Concerning  this 
case  Richter  writes :  '  There  was  a  stone  in  the  ductus 
choledochus  which,  on  account  of  its  uncommon  size,  I  have 
caused  to  be  engraved  in  the  annexed  figure.  It  weighed 
3  ounces  5  drachms.  All  round  the  stone  was  fluid  bile,  so 
that  this  fluid  had  evidently  passed  by  the  stone  into  the 
duodenum.  It  fell  into  three  pieces  on  being  taken  out. 
The  external  surface  resembled  a  very  firm  extract  of 
liquorice.  On  some  places  there  were  evident  marks  of 
other  stones  adhering  to  it.  The  thick  end  of  the  stone  was 
in  the  duodenum  ;  the  most  pointed  was  turned  towards  the 
neck  of  the  gall-bladder.' 

[  215  ] 


216    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

They  may  be  round,  egg-shaped,  barrel-shaped,  elongated 
with  pointed  ends,  or  angular,  the  surface  being  smooth, 
mammillated,  or  irregularly  faceted.  Gall-stones,  when  large, 
are  often  single,  but  when  small  or  moderate  in  size  they 
are  usually  numerous,  and  several  hundreds  may  be  found ; 
for  instance,  in  Case  107,  there  were  successfully  removed 
by  cholecystotomy  no  less  than  720  gall-stones  from  the 
gall-bladder  and  dilated  cystic  duct  of  a  woman  aged  fifty- 
six,  and  cases  are  on  record  where  over  a  thousand  gall- 
stones have  been  removed.  In  a  patient  of  mine  operated 
on  in  the  Leeds  Infirmary  there  were  considerably  over 
a  thousand  removed,  and  in  one  recently  reported  by 
Dr.  E.  T.  Davies  (British  Medical  Journal,  p.  201,  1903) 
no  less  a  number  than  1,754  gall-stones  were  removed 
from  a  woman  aged  fifty-one.  Their  colour  is  variable  ;  in 
some  cases  it  is  white  or  gray,  in  others  very  dark,  or  even 
quite  black,  but  the  usual  colour  is  a  dark  yellow  or  brown. 
In  consistency  they  are  ordinarily  firm,  but  as  a  rule  they 
may  without  much  difficulty  be  fractured  by  pressure  between 
the  thumb  and  forefinger,  the  fracture  being  crystalline ; 
they  may,  however,  be  as  hard  as  a  lithic  acid  calculus,  or 
as  soft  as  half-set  putty.  The  chief  constituent  of  gall- 
stones is  cholesterin,  which  always  occurs  in  the  crystalline 
form ;  but  bile-pigments,  bile-salts,  lime,  mucus,  degenerated 
epithelium,  and  rarely  foreign  bodies,  may  enter  into  their 
composition.  Margarate,  stearate,  and  palmitate  of  lime, 
combined  with  mucus,  usually  form  the  cement  which  binds 
the  cholesterin  crystals  together  to  form  a  concretion. 

Gall-stones  formed  almost  entirely  of  bile-pigment  may  be 
seen.  On  two  occasions  among  the  series  of  operations  given 
in  the  Appendix,  there  were  found  soft  concretions  of  this 
nature  in  large  numbers  in  the  hepatic  ducts  within  the  liver, 
and  in  one  case  where  jaundice  had  been  present  for  many 
years  the  common  duct  was  occupied  by  a  black  putty-like 
substance,  which  had  to  be  removed  by  the  scoop.  Since 
cholesterin  is  the  chief  constitutent  of  gall-stones,  in  con- 
sidering their  formation  our  attention  must  be  directed 
chiefly  to  the  physiology  of  this  monatomic  alcohol,  which 
occurs  normally  not  only  in  the  blood,  but  also  in  the  various 


GALL-STONES,  OR  CHOLELITHIASIS  2\? 

organs  of  the  body.  Although  cholesterin  is  always  present 
in  the  blood  in  a  proportion — according  to  various  authors 
—  varying  from  0*045  to  o'i2  per  cent.,  very  little  is 
known  of  the  processes  which  determine  its  existence.  As 
there  is  no  proof  that  the  liver  excretes  cholesterin  from  the 
blood,  or  that  it  is  a  result  of  hepatic  metabolism,  we  are 
driven  to  the  conclusion  that  it  is  formed  in  the  bile-ducts 
or  the  gall-bladder ;  and,  as  it  is  found  in  other  mucous 
channels  not  transmitting  bile,  there  is  no  reason  to  believe 
that  it  is  formed  from  any  constituent  of  the  bile,  but  rather 
that  it  is  a  product  of  the  epithelium  of  the  bile  passages. 

That  cholesterin,  when  ordinarily  present  in  all  persons, 
should  form  concretions  in  some  and  not  in  others  may 
depend  on  several  causes  ;  possibly  in  some  cases  cholesterin 
occurs  in  positive  excess,  while  in  others  there  may  be  a 
diminution  of  the  bile-salts  which  should  hold  it  in  solution, 
or  it  may  be  precipitated  from  solution  under  certain  con- 
ditions. There  is  no  doubt  that  catarrh  of  the  mucous 
membrane  of  the  bile  passages  increases  the  amount  of 
cholesterin  present,  and  that  the  longer  bile  remains  in  the 
gall-bladder  the  more  cholesterin  will  it  contain.  Anything, 
therefore,  which  causes  stagnation  of  bile  may  predispose  to 
gall-stones.  On  the  other  hand,  whatever  leads  to  a  regular 
emptying  of  the  bile  passages  will  tend  to  clear  out  such 
detritus  as  cast-off  cells,  incipient  collections  of  cholesterin 
crystals  and  mucus,  and  thus  to  prevent  the  formation  of 
gall-stones. 

The  view  is  gaining  ground  that  all  biliary  calculi  have  a 
bacterial  origin,  the  organisms  principally  concerned  being 
the  Bacillus  coli  communis  or  the  typhoid  bacillus,  though 
other  organisms  may  participate  in  the  process.  Bernheim, 
in  1880,  was  the  first  to  direct  attention  to  the  connection 
between  typhoid  fever  and  cholelithiasis.  In  Professor  Hal- 
stead's  clinic  about  one-third  of  the  cases  operated  on  for 
gall-stones  gave  a  history  of  typhoid  fever  at  intervals  of 
from  a  few  months  to  several  years.  We  have  noted  the 
previous  history  of  typhoid  in  many  cases  of  cholelithiasis, 
and  in  some  the  relation  between  the  two  has  seemed  very 
direct. 


2i8    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

The  occurrence  of  the  fever  may  be  long  antecedent  to  the 
appearance  of  symptoms  of  cholelithiasis,  and  yet  the  relation- 
ship may  be  a  true  cause  and  effect.  Thus,  in  Case  262  the 
patient,  aged  forty-eight,  gave  a  history  of  typhoid  fever 
twenty  years  previously,  accompanied  by  pain  and  tender- 
ness beneath  the  right  costal  margin,  and  followed  within 
the  year  by  so-called  '  spasms,'  which  had  continued,  with 
intermissions,  for  the  whole  intervening  period.  The  attacks 
for  the  last  two  years  had  been  regularly  followed  by  slight 
jaundice  and  accompanied  by  pain  over  the  left  side  of  the 
abdomen  and  by  vomiting,  the  whole  leading  to  great 
deterioration  of  health,  and  to  loss  of  weight  to  the  extent  of 
3  stones.  When  seen  there  was  tenderness  at  a  point  mid- 
way between  the  ninth  costal  cartilage  and  the  umbilicus, 
which  we  have  found  to  be  almost  as  significant  of  inflam- 
matory trouble  about  the  gall-bladder  as  is  tenderness  at 
McBurney's  point  of  appendicitis.  This  sign,  together  with 
slight  icterus  after  each  attack,  led  to  the  diagnosis  of  gall- 
stones, although  the  pain  had  latterly  been  more  especially 
on  the  left  side  of  the  abdomen.  The  left-sided  pain,  as  we 
pointed  out  some  years  ago,  is  generally,  if  not  always, 
associated  with  adhesions  between  the  pylorus  and  gall- 
bladder or  bile-ducts,  and  from  observations  on  a  number 
of  cases  it  almost  seems  as  if,  when  this  event  occurs,  a 
transference  of  the  pain  may  take  place  from  the  right  to  the 
left  side,  as  in  reflected  pain  in  other  parts  of  the  body.  In 
the  first  case  on  which  I  made  the  observation  there  was 
also  well-marked  dilatation  of  the  stomach,  showing  that 
the  visceral  adhesions  were  producing  a  difficulty  in  the 
passage  of  food  into  the  duodenum.  At  the  operation  the 
diagnosis  was  confirmed  in  every  particular,  and  after  the 
removal  of  forty-six  gall-stones  from  the  cystic  duct  (one  of 
them  projecting  into  the  common  duct),  and  detaching 
adhesions,  the  gall-bladder  was  drained.  Recovery  was 
uninterrupted,  and  the  patient  is  now  well  in  every  respect. 
There  has  been  no  pain  since  and  no  vomiting,  digestion  is 
perfect,  and  the  patient  has  regained  her  lost  weight.  In 
numerous  cases  since,  these  original  observations  have  been 
confirmed  by  myself  and  many  other  surgeons. 


GALL-STONES,  OR  CHOLELITHIASIS  219 

In  1886  microbes  were  found  in  biliary  calculi  by  M.  Galippe. 
Gilbert,  Dominici,  and  Fournier  examined  calculi  from 
seventy  cases,  and  found  the  Bacillus  coli  communis  either 
living  or  dead  in  one-third  of  the  cases.  They  have  per- 
formed a  number  of  experiments  {Archives  Generates  dc 
Medecine,  September,  1898)  on  animals,  which  seem  to  show 
that  not  only  do  the  Bacillus  coli  communis  and  the  typhoid 
bacillus  set  up  a  cholecystitis,  but  that  this  tends  to  the 
formation  of  gall-stones.  In  two  cases  they  succeeded  in 
inducing  the  formation  of  perfect  calculi  in  a  dog  and  a 
rabbit  injected  with  the  Bacillus  coli  communis.  Mignot 
{ibid.,  August,  1898,  and  British  Medical  Journal  Supplement, 
December  3,  1898)  has  not  only  confirmed  these  observa- 
tions, but  has  gone  further.  He  succeeded  in  producing 
typical  calculi  in  guinea-pigs,  and  obtained  the  following 
results  : 

1.  Foreign  bodies  when  introduced  into  the  gall-bladder 
can  stay  there  for  an  indefinite  time,  provided  they  are 
aseptic,  without  causing  inflammation  or  precipitating  the 
solids  from  the  bile. 

2.  Foreign  bodies  previously  impregnated  with  virulent 
micro-organisms  cause  a  more  or  less  intense  cholecystitis, 
and  precipitate  the  solids  from  the  bile.  As  long  as  the 
bacteria  retain  their  virulence,  however,  they  cannot  form 
a  calculus,  but  only  a  sediment  mixed  with  pus.  This 
sediment  has  no  tendency  to  cohere,  or  to  adhere  to  foreign 
bodies. 

He  then  shows  why  previous  attempts  to  form  calculi 
have  failed.  The  bacteria  must  be  attenuated,  not  virulent. 
This  is  best  attained  by  growing  them  for  some  months  in 
bile  to  which  constantly  decreasing  amounts  of  broth  are 
added.  When  sufficiently  attenuated  they  are  no  longer 
pathogenic  when  injected  into  the  cellular  tissue  of  animals. 
On  injecting  these  into  the  gall-bladder  stones  are  occasion- 
ally formed,  but  more  often  the  bacteria  are  washed  out  into 
the  intestine.  If,  however,  a  foreign  body,  especially  if 
porous,  such  as  cotton-wool,  be  placed  in  the  bladder  and 
fixed  to  its  walls  to  prevent  expulsion,  a  stone  is  formed 
round  it  with  the  greatest  certainty.     Five  or  six  months  are 


22o    DISEASES  OF  THE  GALLBLADDER  AND  BILE-DUCTS 

required  for  the  perfect  formation  of  a  calculus.  The  form 
of  bacteria  injected  seems  to  be  of  secondary  importance. 
Mignot  has  proved  that  the  typhoid  bacillus,  the  Bacillus 
coli,  staphylococci,  streptococci,  and  even  the  non-pathogenic 
Bacillus  subtilis,  are  capable  of  giving  rise  to  calculi,  and 
probably  a  great  number  of  other  organisms  are  equally 
potent. 

Cushing  (Johns  Hopkins  Hospital  Bulletin,  No.  86,  May, 
1898)  has  reported  several  cases  of  cholelithiasis  following 
typhoid  fever  occurring  at  the  Johns  Hopkins  Hospital. 

One  case  of  empyema  of  the  gall-bladder  with  numerous 
calculi  was  operated  on  b}r  Halstead  three  and  a  half  months 
after  an  attack  of  uncomplicated  typhoid.  The  Bacillus 
typhosus  was  cultivated  from  the  contents  of  the  gall-bladder. 

In  another  case  of  cholelithiasis  there  was  no  history  of 
typhoid  fever,  but  the  Bacillus  typhosus  was  grown  in  pure 
culture  from  the  fluid  in  the  gall-bladder.  The  blood-serum 
also  gave  the  Widal  reaction. 

He  has  also  reported  five  other  cases  in  which  cholecysto- 
tomy  was  performed  for  gall-stones  at  varying  intervals  after 
an  attack  of  typhoid  fever.  The  Bacillus  coli  communis  was 
cultivated  from  the  contents  of  the  gall-bladder,  but  no 
typhoid  bacilli  were  found.  From  a  history  of  the  cases 
he  draws  the  following  conclusions  : 

1.  The  bacillus  during  the  course  of  typhoidal  infection 
quite  constantly  invades  the  gall-bladder. 

2.  The  organisms  retain  their  vitality  in  this  habitat  for  a 
long  period. 

3.  In  the  course  of  time  the  bacilli  are  almost  invariably 
found  to  be  clumped  in  the  bile,  suggesting  the  occurrence  of 
an  intravesical  agglutinative  reaction. 

4.  These  clumps  presumably  represent  nuclei  for  the 
deposit  of  biliary  salts,  as  micro  -  organisms  may  with 
regularity  be  demonstrated  in  the  centres  of  recently- formed 
stones. 

5.  Gall-stones  being  present  in  association  with  the  latent, 
long-lived,  infective  agents,  an  inflammatory  reaction  in  the 
viscus  of  varying  intensity  may  be  provoked  at  any  sub- 
sequent period. 


GALL-STONES,  OR  CHOLELITHIASIS  22  r 

Among  the  remoter  causes  we  must  consider  age,  sex, 
habits,  dress,  diet,  diathetic  condition,  and  disease. 

Age. — Although  gall-stones  may  occur  at  any  age,  even  in 
the  newly-born,  they  are  rarely  found  under  the  age  of 
twenty-five  or  thirty.  Schroeder  says  that  under  the  age 
of  twenty  the  percentage  is  2*4  ;  from  twenty  to  thirty,  3*2  ; 
from  thirty  to  forty,  11*5;  from  forty  to  fifty,  in;  from 
fifty  to  sixty,  9*9;  and  over  sixty,  25*2  per  cent.  Judging 
from  a  paper  (British  Medical  Journal,  April  8,  1899)  by 
Dr.  G.  F.  Still,  biliary  calculi  in  young  children  are  met 
with  not  infrequently.  He  gives  three  cases  in  which  a 
necropsy  had  been  performed  within  six  months  at  the 
Great  Ormond  Street  Hospital  for  Children.  In  the  first, 
a  child  aged  nine  months,  there  were  vomiting  and  clay- 
coloured  stools,  but  neither  jaundice  nor  colic.  After  death 
(which  occurred  from  other  causes)  there  were  found  eleven 
small,  black,  friable  calculi  composed  of  pigment,  three  of 
which  were  impacted  in  the  common  duct.  The  second 
case  was  that  of  a  girl,  aged  eight  months,  who  died  of 
tuberculous  meningitis.  There  was  neither  jaundice  nor 
abdominal  pain  ;  but  at  the  post-mortem  examination  there 
were  found  three  minute  calculi  of  pigment  in  the  gall- 
bladder. In  the  third  case,  a  boy  (age  not  given),  there 
were  abdominal  pain  and  vomiting,  but  no  jaundice;  the 
calculi  were  of  the  same  kind.  He  described  a  fourth  case 
where  there  had  been  recurrences  of  vomiting,  abdominal 
pain,  and  jaundice.  Altogether  he  has  been  able  to  collect 
twenty  cases  in  children,  ten  of  which  were  in  infants.  He 
was  of  opinion  that  biliary  calculi  might  be  formed  during 
intra-uterine  life,  and  thought  that  the  viscosity  of  the  bile 
in  infancy  was  probably  connected  with  the  formation  of 
such  concretions. 

Sex. — Gall-stones  occur  more  frequently  in  women  than 
in  men.  Schroeder  states  that  in  Germany  they  are  found 
in  20  per  cent,  of  female  and  in  4*4  per  cent,  of  male 
necropsies.  Out  of  228  autopsies  on  women  in  the  Man- 
chester Royal  Infirmary,  Dr.  Brockbank  found  18,  and  out 
of  542  post-mortem  examinations  in  men  16  cases  of  gall- 
stones, which  gives  7*9  per  cent,  in  females,  and  2*9  per  cent. 


222    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

n  male  subjects.  Pregnancy  would  seem  to  be  a  factor  in 
the  causation  of  gall-stones,  as  in  a  large  series  of  cases 
90  per  cent,  of  the  women  affected  had  borne  children.  The 
wearing  of  corsets,  which  tends  to  force  down  the  front  of 
the  liver,  and  to  depress  the  fundus  of  the  gall-bladder,  is 
probably  a  distinct  etiological  factor,  especially  when  com- 
bined with  deficient  exercise. 

Habits. — Want  of  exercise,  whether  from  lethargy  or  from 
necessity,  as  in  some  forms  of  chronic  heart  disease,  leads 
to  stagnation  of  bile  in  the  gall-bladder,  and  to  the  deposi- 
tion of  cholesterin,  since  the  gall-bladder  is  unaided  in  its 
expulsive  efforts  by  the  contraction  of  the  abdominal 
muscles. 

Diet. — The  following  facts  go  far  to  prove  that  diet  exercises 
a  strong  influence  in  the  formation  of  gall-stones.  It  seems 
probable  that  free  cholesterin  in  the  bile  passages  is  due,  in 
some  cases,  to  a  deficiency  of  its  solvents  in  the  bile,  these 
solvents  being  the  glycocholate  and  taurocholate  of  soda 
which  arise  from  the  metabolism  of  nitrogenous  foods.  If 
the  supply  of  nitrogen  in  the  food  be  limited,  the  bile-salts 
are  likely  to  be  diminished,  and  cholesterin  may  be  pre- 
cipitated. This  may  serve  to  explain  the  presence  of  gall- 
stones in  gouty  persons,  who,  on  account  of  their  uric  acid 
diathesis,  limit  their  intake  of  nitrogen.  The  larger  con- 
sumption of  farinaceous  food  in  Germany  may  also  serve  to 
explain  the  greater  prevalence  of  gall-stones  there  than  in 
England,  where  meat  enters  more  extensively  into  the  dietary. 
In  diabetes,  where  nitrogenous  food  is  prescribed,  gall-stones 
are  rarely  found.  Dr.  Thudichum,  in  his  work  on  gall-stones, 
states  that  he  cannot  find  any  recorded  instances  of  the 
discovery  of  gall-stones  in  the  wild  carnivora,  though  on 
two  occasions  they  have  been  found  in  the  gall-bladders  of 
domesticated  carnivora.  On  the  other  hand,  Dr.  Brockbank 
could  find  no  evidence  of  their  occurrence  in  wild  herbivora, 
though  at  times  they  are  found  in  domesticated  horses, 
cattle,  and  sheep,  as  well  as  in  pigs.  Moreover,  in  pampered 
dogs  fed  on  farinaceous  foods  they  are  found  occasionally. 
In  man,  who  is  omnivorous,  they  occur  in  from  5  to  10  per 
cent.      It   will  thus   be   seen   that   in   those   who   take   an 


GALL-STONES,  OR  CHOLELITHIASIS 


--j 


abundance  of  albuminous  materials  in  their  food,  and  where, 
therefore,  the  bile-salts  are  in  sufficient  quantity,  there  is 
little  tendency  to  the  deposition  of  cholesterin,  whereas 
when  little  albuminous  food  is  taken,  and  the  bile-salts  are 
presumably  insufficient  to  hold  the  cholesterin  in  solution, 
gall-stones  are  likely  to  form  ;  this  tendency  is  aided  by 
insufficient  exercise,  as  in  stall-fed  cattle,  pampered  dogs, 
and  indolent  men.  The  formation  of  some  gall-stones  con- 
taining lime  has  been  attributed  to  the  drinking  of  hard 
water,  but  this  is  by  no  means  proved ;  an  insufficiency  of 
diluent  drinks  may,  however,  possibly  act  as  a  cause. 

A  case  of  Dr.  Hofman's  is  of  interest  as  showing  the  time 
in  which  gall-stones  may  form.  In  April,  1895,  he  removed 
a  number  of  stones  from  the  gall-bladder,  and  used  silk 
sutures;  the  symptoms  returning  at  the  end  of  1896,  chole- 
cystotomy  was  again  performed  in  June,  1897,  and  several 
good-sized  stones  were  removed  and  found  to  have  the  silk 
sutures  as  their  nuclei.  And  I  know  of  one  case  where  the 
silk  suture  employed  to  stitch  up  the  opening  in  the  common 
duct  in  a  choledochotomy  led  to  the  formation  of  a  con- 
cretion, which  was  fortunately  passed  naturally,  and  an 
examination  of  the  gall-stone  showed  the  ligature  to  be  the 
nucleus. 

Symptoms. — In  discussing  the  symptoms  of  cholelithiasis, 
we  must  note,  in  the  first  place,  that  gall-stones  may  be 
found  post-mortem  without  having  produced  any  symptoms 
during  life.  In  such  cases  they  are,  as  a  rule,  in  the  gall- 
bladder, while  the  ducts  are  free,  and  there  are  no  signs  of 
irritation  in  the  shape  of  adhesions.  Indeed,  there  can  be 
no  doubt  that  a  large  gall-stone  may  even  ulcerate  its  way 
into  the  bowel,  and  produce  symptoms  of  intestinal  obstruc- 
tion, with  few  or  no  signs  to  indicate  that  such  serious  organic 
mischief  has  been  going  on.  Several  such  cases  are  related 
in  the  chapter  on  Intestinal  Obstruction  from  Gall-stones. 
It  follows,  therefore,  that  in  considering  cases  of  intestinal 
obstruction  gall-stones  cannot  be  excluded,  though  there  has 
been  no  symptom  of  cholelithiasis.  It  is  just  possible  that 
as  some  persons  pass  urinary  stones  with  few  or  no  symptoms, 
so  others  may  pass  small  biliary  calculi ;  this,  however,  has 


224    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

yet  to  be  proved,  and  in  the  meantime  it  is  difficult  to  explain 
why  in  some  persons  gall-stones  should  produce  such  serious 
troubles,  while  in  others  they  give  rise  to  none  at  all. 

In  certain  cases  there  may  be  a  history  of  dyspepsia,  with 
depression  of  spirits  and  a  feeling  of  discomfort  or  weight,  or 
even  ill-defined  pains  over  the  right  side  of  the  abdomen,  but 
an  entire  absence  of  those  characteristic  symptoms  which  give 
definiteness  to  diagnosis. 

The  ordinary  symptoms  of  cholelithiasis  are  paroxysmal 
attacks  of  pain,  which,  occurring  at  irregular  intervals,  and 
often  without  apparent  cause,  start  in  the  right  hypochon- 
drium  or  in  the  epigastrium,  and  radiate  thence  over  the 
abdomen  and  through  to  the  right  subscapular  region. 
These  attacks  are  often  accompanied  by  sickness  or  vomiting, 
and  if  severe  by  collapse.  They  may  be  followed  by  jaundice, 
with  its  well-known  symptoms,  but  this  is  frequently  absent. 
At  times  a  feeling  of  fulness  in  the  right  hypochondrium 
accompanies  the  attack  ;  but  the  formation  of  a  tumour  does 
not  occur,  as  a  rule,  unless  the  ducts  are  blocked.  Accom- 
panying these  special  symptoms  will  usually  be  found  de- 
pression of  spirits,  want  of  appetite,  dyspepsia,  and  loss  of 
weight. 

According  to  Naunyn,  there  is  a  regular  as  well  as  an 
irregular  form  of  the  disease.  The  former  occurs  where  the 
calculi  are  simply  lodged  in  the  gall-bladder  or  pass  along 
the  ducts  ;  the  latter  is  seen  when  there  is  infectious  angio- 
cholitis,  with  abscess  in  the  liver,  fistula,  or  other  complica- 
tions. (See  section  on  inflammatory  affections  of  the  gall- 
bladder and  bile-ducts.) 

The  following  symptoms  will  be  considered  in  detail : 

(a)  Paroxysmal  pain. — For  the  most  part  the  patient  com- 
plains of  pain  under  the  right  costal  margin,  or  in  the  epigas- 
trium, whence  it  radiates  over  the  abdomen  and  to  the  right 
subscapular  region  ;  but  in  some  cases  the  pain  radiates  to 
the  left  shoulder.  These  attacks  come  suddenly  when  the 
patient  is  quite  well,  and  usually  end  by  causing  nausea  or 
an  attack  of  vomiting.  The  vomiting  leads  to  relaxation  of 
the  duct,  and  if  the  gall-stone  be  small  it  may  pass  on  and 
thus  end  the  attack.     The  seizures  come  on  without  apparent 


GALL-STONES,  OR  CHOLELITHIASIS  225 

cause,  although  at  times  they  may  appear  to  be  brought  on 
by  exertion  or  by  taking  food.  Not  infrequently,  after  an 
attack  has  passed  off,  a  dull  aching  is  felt  in  the  region  of  the 
gall-bladder  for  some  time,  perhaps  until  another  seizure. 
In  several  cases  we  have  noticed  the  pain  to  begin  on  the 
left  side  over  the  stomach,  and  in  these  we  have  always 
found  adhesion  of  the  stomach  to  the  gall-bladder  or  bile- 
ducts. 

The  pain  may  be  irregular,  at  times  simulating  angina 
pectoris  and  being  almost  limited  to  the  pre-cordial  region, 
or  epigastric,  simulating  ulcer  of  the  stomach,  or  genito-crural 
and  resembling  renal  calculus.  The  absence  of  other  cardiac, 
stomach,  or  renal  symptoms,  and  the  presence  of  tenderness 
over  the  gall-bladder  or  in  the  line  between  the  umbilicus  and 
the  ninth  costal  cartilage,  will  usually  enable  a  diagnosis  to 
be  made. 

It  is  not  uncommon  for  the  pain  to  commence  in  the 
epigastrium,  and  to  radiate  thence  all  over  the  abdomen, 
especially  into  both  hypochondriac  regions  ;  it  may  then  pass 
through  to  the  midscapular  region,  and  even  pass  up  to  the 
head  and  neck  or  down  to  the  loin. 

(b)  Vomiting. — Though,  as  a  rule,  the  vomiting  is 
paroxysmal  and  associated  with  colic,  it  may  be  almost 
continuous,  and  so  of  itself  prove  dangerous.  In  one  case 
of  this  kind  (No.  29)  the  patient  was  so  weak  from  persistent 
vomiting  that  it  was  feared  she  scarcely  could  bear  the 
operation  it  was  necessary  to  perform.  Even  after  the  source 
of  irritation  had  been  removed  the  vomiting  persisted  for 
days ;  ultimately,  however,  she  made  a  good  recovery.  In 
another  case,  which  was  seen  in  the  South  of  Ireland 
(No.  92),  the  vomiting  had  been  so  incessant  that  the  patient 
had  been  fed  almost  solely  by  nutrient  enemata  for  six  weeks 
before  operation,  and  even  afterwards,  though  the  operation 
was  satisfactory  and  the  after-progress  in  other  respects  all 
that  could  be  desired,  the  emesis  persisted  for  a  fortnight, 
and  ultimately  caused  the  death  of  the  patient  from  sheer 
exhaustion.  The  vomiting,  as  a  rule,  occurs  towards  the 
end  of  the  seizure,  and,  in  fact,  frequently  determines  its 
cessation.      In    such    cases    the   stomach  contents   are   first 

15 


226    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

rejected,  after  which,  if  the  common  duct  be  free,  bile  is 
vomited ;  at  times,  however,  in  the  severe  cases,  vomiting 
becomes  grumous  or  even  stercoraceous. 

(c)  Collapse. — Occasionally  a  patient  becomes  so  profoundly 
collapsed  from  an  attack  of  gall-stone  colic  as  to  give  rise  to 
great  difficulty  in  diagnosis,  the  case  being  more  like  one  of 
perforation  of  some  abdominal  viscus  or  of  intra-abdominal 
haemorrhage  ;  but  the  history  of  previous  seizures  and  of  the 
onset  of  the  attack  from  which  the  patient  is  suffering  will 
usually  help  one  to  arrive  at  a  correct  diagnosis.  The  acute, 
agonizing  pain  may  of  itself  cause  death,  as  in  the  case  of 
a  lady  seen  by  the  author  in  consultation,  and  where  the 
presence  of  gall-stones  was  diagnosed.  The  next  attack  of 
pain  unfortunately  proved  fatal,  and  at  the  autopsy  a  gall- 
stone was  found  half  extruded  into  the  duodenum. 

Not  only  may  the  agonizing  pain  of  a  single  attack  prove 
fatal,  but  repeated  attacks  of  pain  occurring  without  sufficient 
interval  for  recuperation  may  produce  very  serious  deteriora- 
tion of  health,  or  even  death  from  sheer  exhaustion. 

(d)  The  formation  of  a  tumour  in  the  region  of  the  gall- 
bladder is  seldom  seen  in  acute  cases ;  but  it  may  be  noticed 
with  each  attack,  and  is  then  due  to  the  violent  contraction 
of  the  muscular  wall  of  the  gall-bladder  on  its  contents.  It 
is,  however,  a  frequent  sign  in  the  more  chronic  cases,  and 
is  fully  discussed  in  the  section  on  tumours  of  the  gall- 
bladder. 

(e)  The  presence  of  gall-stones  in  the  motions  after  an  attack  is 
valuable  evidence,  but  their  absence  does  not  negative 
cholelithiasis.  It  is  quite  usual  in  cases  submitted  to  opera- 
tion to  find  gall-stones  where  none  had  at  any  time  been 
detected  in  the  motions,  although  diligently  looked  for  after 
attacks  of  colic. 

The  way  to  search  for  gall-stones  is  to  let  the  patient  pass 
the  motion  into  a  solution  of  carbolic  acid,  to  have  it  well 
stirred,  and  then  to  pass  it  through  a  fine  sieve  with  about 
,',.,  inch  mesh. 

(/)  Jaundice. — So  long  as  the  gall-stones  are  in  the  gall- 
bladder or  cystic  duct  there  is  nothing  to  prevent  the  bile 
passing  down  the  common  duct  into  the  intestine.     Jaundice 


GALL-STONES,  OR  CHOLELITHIASIS  227 

is  therefore  absent  in  the  greater  number  of  cases  of  chole- 
lithiasis, or,  if  present,  shows  only  as  a  slight  icteric  tinge  in 
the  conjunctivae,  which  is  induced  by  catarrh  spreading 
from  the  gall-bladder  and  cystic  duct  to  the  common  and 
hepatic  ducts.  Should  the  gall-stones  be  impacted  in  the 
common  duct,  the  passage  of  bile  is  obstructed  and  jaundice 
ensues.  Intermittent  jaundice  may  also  occur  if  a  small 
gall-stone  in  the  common  duct  acts  as  a  ball-valve.  In 
deeply  jaundiced  cases  a  decision  concerning  operation  is 
frequently  difficult,  since  chronic  jaundice  too  often  indicates 
malignant  disease  ;  and  not  only  do  patients  with  cancer  bear 
operations  badly,  but  when  jaundice  is  associated  with  it 
there  is  the  same  tendency  to  persistent  oozing  of  blood 
from  the  wound  after  operation  as  there  is  to  spontaneous 
haemorrhage  where  no  operative  measures  have  been  under- 
taken, and  though  this  haemorrhagic  tendency  may  be 
checked  by  the  administration  of  calcium  chloride,  there  is  a 
want  of  healing  power,  and  often  a  feeble  resistance  to  shock, 
rendering  operation  in  these  cases  more  serious  than  in 
ordinary  gall-stone  subjects. 

Dr.  Ord  drew  attention  to  the  production  of  intermittent 
pyrexia  by  gall-stones,  and  stated  that  his  attention  had  first 
been  called  to  this  symptom  by  some  remarks  of  the  late 
Dr.  Murchison  on  the  case  of  a  distinguished  medical  officer, 
who,  after  his  return  to  England,  was  attacked  at  regular 
weekly  intervals  with  paroxysms  of  shivering,  followed  by 
fever  and  sweating.  He  was  supposed  at  first  to  have  a 
recurrence  of  an  old  intermittent  fever,  and,  later,  to  have 
hepatic  abscess,  but  at  last  his  symptoms  indicated,  and  the 
necropsy  proved,  that  his  actual  and  only  disease  was  a  gall- 
stone so  impacted  as  to  produce  great  irritation,  but  not 
complete  obstruction,  of  the  common  duct.  Similar  cases 
had  been  noticed  by  Charcot,  who  argued  that  the  fever 
is  due  to  the  absorption  of  some  poison  into  the  blood. 
Dr.  Murchison  was  of  opinion  that  such  attacks  are  not  of 
a  poisonous  or  septic  origin,  but  are  due  to  nervous  irritation. 
From  the  cases  we  have  seen,  we  should  think  that  both 
explanations  are  admissible,  the  fever  being  not  unlike  that 
known  as  '  urethral,'  in  which  the    same  contention   as   to 

15—2 


228    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

causation  arises :  but  seeing  that  the  bile  is  alway  septic  in 
these  cases,  we  consider  the  chief  cause  of  the  fever  to  be 
ordinarily  septic  absorption  from  the  damming  back  of  the 
infected  bile,  which  thus  becomes  absorbed  by  the  lymphatics 
and  conveyed  into  the  blood-stream. 

Dr.  Osier  says  that  the  combination  of  the  following 
symptoms  is  characteristic  of  the  existence  of  gall-stones  in 
the  common  duct,  and  is  therefore  valuable  in  distinguishing 
between  this  form  of  obstruction  and  that  arising  from 
malignant  tumour  alone : 

i.  Jaundice  of  varying  intensity,  deepening  after  each 
paroxysm,  which  may  persist  for  months  or  even  years. 

2.  Ague-like  paroxysms,  characterized  by  chill,  sweating, 
and  fever,  and  followed  by  deepening  of  the  pre-existent 
jaundice. 

3.  At  the  time  of  the  paroxysm  pains  in  the  region  of  the 
liver,  with  epigastric  disturbance. 

This  opinion  is  fully  borne  out  by  our  experience,  and  in 
a  number  of  cases  of  jaundice  of  several  months'  duration, 
where  there  was  this  combination  of  symptoms,  gall-stones 
were  found  in  the  common  duct. 

In  addition  to  the  symptoms  already  mentioned,  the 
following  complications  may  be  met  with,  and  may  constitute 
the  prominent  conditions  threatening  life  and  requiring 
treatment,  the  original  cause  having,  perhaps,  disappeared 
or  become  masked  by  its  more  serious  sequelae  : 

1.  Ileus  due  to  atony  of  the  bowel,  leading  to  enormous 
distension,  and  to  the  symptoms  and  appearances  of  acute 
intestinal  obstruction,  apparently  the  consequence  of  the 
violent  pain. 

2.  Acute  intestinal  obstruction  dependent  on  : 

{a)   Paralysis  of  gut    due  to  local    peritonitis    in   the 

neighbourhood  of  the  gall-bladder. 
{b)  Volvulus  of  small  intestine. 

(c)  Stricture     of     intestine     by    adventitious    bands 

originally  produced  as  a  result  of  gall-stones. 

(d)  Impaction  of  a  large  gall-stone  in  some  part  of  the 

intestine  after  ulcerating  its  way  from  the  bile 
channels  into  the  bowel. 


GALL-STONES,  OR  CHOLELITHIASIS  229 

3.  General  haemorrhages,  the  result  of  long-continued 
jaundice,  dependent  either  on  gall-stones  alone  or  on  chole- 
lithiasis associated  with  malignant  disease. 

4.  Localized  peritonitis,  producing  adhesions,  which  may 
then  become  a  source  of  pain  even  after  the  gall-stones  have 
been  got  rid  of.  We  believe  that  nearly  every  serious  attack 
of  biliary  colic  is  accompanied  by  adhesive  peritonitis,  as 
experience  shows  that  adhesions  are  found  practically  in  all 
cases  where  there  have  been  characteristic  seizures. 

5.  Dilatation  of  the  stomach  dependent  on  adhesions 
around  the  pylorus. 

6.  Ulceration  of  the  bile  passages,  establishing  a  fistula 
between  them  and  the  intestine. 

7.  Stricture  of  the  cystic  or  common  duct. 

8.  Abscess  of  the  liver. 

9.  Localized  peritoneal  abscess. 

10.  Abscess  in  the  abdominal  wall. 

11.  Fistula  at  the  umbilicus,  or  elsewhere  on  the  surface 
of  the  abdomen,  discharging  mucus,  muco-pus,  or  bile. 

12.  Empyema  of  the  gall-bladder. 

13.  Infective  and  suppurative  cholangitis. 

14.  Septicaemia  or  pyaemia. 

15.  Phlegmonous  cholecystitis. 

16.  Gangrene  of  the  gall-bladder. 

17.  Perforative  peritonitis  due  to  ulceration  through,  or  to 
rupture  of,  the  gall-bladder  or  the  ducts,  leading  to  extrava- 
sation of  infected  bile  into  the  general  peritoneal  cavity. 

18.  Pyelitis  on  the  right  side  due  to  a  gall-stone  ulcerating 
its  way  into,  or  an  abscess  of  the  gall-bladder  bursting  into, 
the  pelvis  of  the  kidney. 

19.  Cancer  of  the  gall-bladder  or  ducts. 

20.  Subphrenic  abscess. 

21.  Pleurisy  or  empyema  of  the  gall-bladder. 

22.  Pneumonia  of  the  lower  lobe  of  the  right  lung. 

23.  Chronic  invalidism  and  inability  to  perform  any  of  the 
ordinary  business  or  social  duties  of  life. 

24.  Suppurative  pancreatitis. 

25.  Chronic  interstitial  pancreatitis. 

26.  Infective  endocarditis. 

27.  Cirrhosis  of  liver. 


230    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Diagnosis. — In  the  sections  on  tumours  of  the  gall-bladder 
and  on  inflammatory  affections  of  the  bile  passages  the 
diagnosis  of  the  complications  of  gall-stones  is  more  fully 
dwelt  on,  so  that  here  it  is  only  necessary  to  discuss  uncom- 
plicated cholelithiasis.  In  this  connection  we  have  to 
consider  the  several  ailments  which  may  produce  painful 
seizures  in  the  right  side  of  the  abdomen.  These  are : 
hysteria  or  nervous  spasms,  locomotor  ataxia,  acute  dyspepsia 
with  flatulence,  appendicular  colic  with  appendicitis,  right 
renal  colic,  acute  and  chronic  pancreatitis,  pancreatic 
calculus,  gastric,  pyloric,  or  duodenal  ulcer,  peritoneal  adhe- 
sions to  the  pylorus  or  bowel,  spinal  neuralgia,  malignant 
growth  in  or  near  the  liver,  pyloric  stenosis,  lead  colic, 
angina  pectoris,  pneumonia  and  pleurisy. 

The  diagnosis  rests  chiefly  on  paroxysmal  attacks  of  pain 
starting  in  the  right  hypochondrium  and  radiating  thence 
over  the  abdomen  and  through  to  the  right  scapula,  the 
attacks  being  often  accompanied  by  vomiting  or  collapse, 
and  sometimes  followed  by  jaundice,  although  this  is  fre- 
quently absent.  If  jaundice  be  persistent  and  intense,  without 
variation,  the  presence  of  malignant  disease  should  be  sus- 
pected ;  if  it  be  dependent  on  gall-stones,  ague-like  attacks 
will  probably  occur. 

Just  as  in  appendicitis  there  is  tenderness  over  McBurney's 
point,  so  in  gall-stones,  with  very  few  exceptions,  marked 
tenderness  will  be  found  on  pressing  the  finger  deeply  over 
the  region  of  the  gall-bladder,  or  over  some  point  in  a  line 
from  the  ninth  costal  cartilage  to  the  umbilicus.  In  some 
cases  the  pain  in  the  so-called  '  spasms  '  is  referred  to  the 
left  side,  radiating  thence  to  the  left  infrascapular  region  ; 
and  in  operating  on  such  cases  it  will  be  found,  as  mentioned 
above,  that  the  pylorus  is  adherent  to  the  gall-bladder  or 
cystic  duct,  or,  as  in  a  case  on  which  I  operated  recently,  a 
pancreatic  calculus  in  the  body  or  tail  of  the  pancreas  may 
be  found  (Case  487).  In  hysteria  the  irregularity  in  the 
character  of  the  attacks,  their  association  with  other  nervous 
phenomena,  such  as  polyuria,  globus  hystericus,  and  so  forth, 
together  with  the  absence  of  collapse  and  of  the  physical  signs 
of  gall-stones,  will  enable  one  to  arrive  at  a  correct  conclusion. 


GALL-STONES,  OR  CHOLELITHIASIS  231 

The  lightning  pains  of  abdominal  crises  of  locomotor 
ataxia  have  led  to  errors  in  diagnosis,  and  we  have  heard  of 
an  operation  having  been  performed  in  such  a  case,  but  the 
absence  of  knee-jerks  and  the  well-known  ocular  and  other 
nervous  symptoms  should  prevent  this  mistake. 

As  a  rule,  there  will  be  little  difficulty  in  distinguishing 
cholelithiasis  from  acute  dyspepsia  with  flatulence.  The 
relief  following  on  simple  treatment,  the  pain  over  the 
stomach  rather  than  over  the  gall-bladder,  the  discovery  of  a 
manifest  cause,  and  the  absence  of  serious  symptoms,  readily 
enable  the  distinction  between  so-called  '  stomach  spasms 
and  gall-stones  to  be  made. 

In  appendicular  colic  or  appendicitis  the  almost  invariable 
sign  of  tenderness  at  a  point  midway  between  the  anterior 
superior  spine  of  the  right  ilium  and  the  umbilicus 
(McBurney's  point) ;  the  presence  of  a  swelling  in  the  right 
iliac  fossa,  or  near  it ;  the  presence  of  bowel  symptoms  in  the 
shape  of  distension  with  rise  of  temperature  ;  the  character- 
istic initial  vomiting  ;  the  commencement  of  the  pain  around 
or  just  above  the  umbilicus,  and  subsequently  its  transfer 
ence  to  the  right  iliac  region  ;  and  the  absence  of  right 
scapular  pain,  render  the  diagnosis  of  this  condition  free 
from  serious  difficulty,  though  in  cases  of  phlegmonous 
cholecystitis  with  peritonitis  the  latter  has  sometimes  been 
attributed  to  appendicitis  instead  of  to  its  actual  cause. 
Confusion  is  most  likely  to  occur  in  those  cases  in  which  the 
appendix,  in  consequence  of  the  non-descent  of  the  caecum, 
lies  in  close  relation  to  the  gall-bladder.  It  must,  however, 
be  remembered  that  cholelithiasis  and  appendicitis  may  co- 
exist, and,  as  has  been  pointed  out  by  Dr.  Ochsner,  of  Chicago, 
the  one  condition  may  excite  the  other  {Philadelphia  Medical 
Journal,  October  6,  1900).  During  four  months,  out  of 
eighteen  patients  operated  on  for  gall-stones  in  the  Augustina 
Hospital,  six  suffered  at  the  same  time  from  appendicitis. 
The  explanation  given  by  Dr.  Ochsner  is  that  the  gall- 
bladder becomes  infected  from  the  appendix,  either  at  the 
time  of  the  acute  attack  or  during  the  chronic  manifestation 
of  the  disease ;  hence  he  advises  an  examination  of  the 
appendix  in  all  cases  when  operating  on  the  gall-bladder. 


232    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

In  right  renal  colic  the  associated  urinary  symptoms, 
together  with  the  condition  of  the  urine  and  the  pain  over 
the  kidney,  passing  down  the  right  genito-crural  nerve  into 
the  testicle,  are  distinctive.  In  lead  colic  the  more  or  less 
persistent  stomach-ache,  the  constipation,  the  absence  of  the 
usual  gall-bladder  paroxysms,  and  the  presence  of  a  blue  line 
on  the  gums,  will  usually  assist  in  the  diagnosis,  but  in  a 
doubtful  case  the  result  of  treatment  by  iodide  of  potassium 
and  saline  aperients  will  soon  clear  up  the  diagnosis. 

In  pyloric  stenosis,  if  accompanied  by  adhesions  around 
the  pylorus,  the  symptoms  are  not  unlike  those  of  gall-stones, 
with  which,  in  fact,  the  affection  may  be  associated,  as  in 
several  cases  related  by  me  before  the  Clinical  Society  in 
1889  (Transactions  of  Clinical  Society,  1889),  up  to  which 
time,  I  believe,  the  subject  had  not  attracted  attention.  The 
presence  of  dilatation  of  the  stomach,  the  characteristic 
vomit,  the  visible  peristalsis  in  the  stomach  wall,  the  pain  in 
the  left  of  the  abdomen,  and  the  absence  of  the  charac- 
teristic gall-bladder  pain,  will  usually  establish  the  diagnosis. 

Pyloric  or  duodenal  ulcer  may  simulate  gall-stones,  though 
the  association  of  pain  with  food,  and  occurring  one  to  two 
hours  after  it,  the  regular  daily  recurrence  of  pain,  and  the 
presence  of  stomach  symptoms,  generally  render  the  diagnosis 
easy ;  but  where  perigastritis  extends  to  and  involves  the 
common  duct  the  presence  of  jaundice  may  give  rise  to  doubt 
that  can  only  be  settled  by  exploration. 

Chronic  pancreatitis  is  so  frequently  associated  with 
common  duct  cholelithiasis  that  the  differential  diagnosis  is 
rather  of  theoretical  than  practical  interest,  especially  as  the 
treatment  offering  the  best  hope  of  cure  is  drainage  of  the 
bile-ducts.  The  pain  in  chronic  pancreatitis  radiates  to  the 
midscapular  region,  or  round  the  left  side,  and  the  tender- 
ness is  in  the  epigastrium  rather  than  in  the  gall-bladder 
region.  The  presence  of  jaundice  depends  on  the  anatomical 
relation  of  the  head  of  the  pancreas  to  the  common  bile- 
duct,  for  in  some  cases  it  embraces  the  duct,  while  in  others 
it  only  lies  close  to  it.  Jaundice,  therefore,  is  not  a  necessary 
symptom  unless  there  be  at  the  same  time  a  gall-stone  in  the 
common  duct.     In  some  cases  the  swollen  pancreas  can  be 


GALL-STONES,  OR  CHOLELITHIASIS  233 

felt  on  deep  pressure  in  the  epigastrium,  especially  if  an 
anaesthetic  be  employed.  Rapid  loss  of  flesh  is  suggestive 
of  pancreatitis.  The  presence  of  characteristic  crystals 
arranged  in  rosette  form,  obtained  from  the  urine  by  a  special 
process  of  hydrolysis,  has  appeared  to  Mr.  Cammidge  and 
myself  to  be  of  undoubted  diagnostic  importance  in  cases 
where  the  pancreas  is  involved.  Where  the  disease  is  in- 
flammatory the  crystals  are  more  slender,  and  more  speedily 
dissolve  on  boiling  in  acid  than  in  malignant  disease,  where 
the  crystals  are  broader  and  blunter,  and  take  a  much  longer 
time  to  dissolve. 

In  acute  pancreatitis  the  symptom  of  acute  peritonitis  start- 
ing suddenly  in  the  epigastric  region,  and  followed  by  disten- 
sion, at  first  in  the  upper  half  of  the  abdomen,  and  later 
becoming  general,  may  simulate  acute  cholecystitis  due  to 
gall-stones,  but  the  site  of  the  pain,  the  preceding  history, 
the  presence  of  a  tumour  of  the  gall-bladder,  and  the  less 
severe  collapse  in  cholecystitis,  as  a  rule  enable  a  diagnosis 
to  be  made.  In  such  cases  early  treatment  by  exploration  is 
called  for  ;  the  diagnosis  is  therefore  of  theoretical  rather 
than  practical  value. 

In  spinal  neuralgia  the  presence  of  tenderness  over  the 
spine,  the  course  of  the  pain  along  the  branches  of  the  corre- 
sponding spinal  nerves,  and  the  absence  of  collapse  or  of 
vomiting,  put  aside  all  difficulty  in  most  cases. 

In  malignant  disease  the  absence  of  pain  at  the  onset,  or, 
when  present,  its  continuous  character,  the  gradual  and  per- 
sistent loss  of  flesh,  and  the  more  marked  failure  of  strength, 
usually  indicate  the  serious  nature  of  the  affection.  The 
persistence  and  gradual  deepening  of  jaundice  when  once  it 
supervenes,  the  frequent  absence  of  ague-like  attacks,  and,  if 
the  disease  involve  the  head  of  the  pancreas,  the  almost 
constant  presence  of  a  palpable  tumour  due  to  enlargement 
of  the  gall-bladder,  afford  landmarks  which,  as  a  rule,  prove 
true  guides  ;  but  in  many  cases  gall-stones  exist  along  with 
malignant  disease,  and  then  these  distinguishing  symptoms 
become  unreliable,  though  the  rapid  wasting  and  loss  of 
flesh  wrill  often  lead  to  a  successful  diagnosis  of  the  co- 
existence   of  the  two   conditions.     If  nodules  form    in   the 


234    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

liver,  and  ascites  with  cedema  of  the  feet  supervene,  the 
condition  becomes  manifest  at  once.  The  presence  of  small 
angiomata  on  the  skin,  especially  on  that  of  the  abdomen, 
though  not  absolute  proof,  is  a  point  in  favour  of  cancer. 
Leser  {Munch.  Med.  ]Voch.,  December  17,  1901)  drew  attention 
to  it,  though  Freund  and  Hollander  had  previously  noticed 
it  without  laying  great  stress  on  its  importance. 

From  right-sided  pleurisy  and  pneumonia  the  physical 
signs  afford  positive  evidence,  and  the  symptoms  are  usually 
so  distinct  and  definite  as  to  leave  no  doubt. 

Angina  pectoris,  by  its  sudden  and  irregular  onset  and  the 
presence  of  collapse,  may  give  rise  to  the  suspicion  of  gall- 
stones, and  I  have  seen  the  mistake  made  in  practice  ;  but  the 
situation  of  the  pain  in  the  pre-cordial  region,  and  its  passage 
down  the  left  arm,  together  with  the  usual  circulatory  dis- 
turbances, and  maybe  the  presence  of  organic  disease  in  the 
heart  or  vessels,  will  usually  afford  a  sufficient  guide  to 
prevent  a  mistake  being  made. 

Slight  jaundice  is  very  frequently  present  in  true  gall- 
stone seizures,  even  when  the  concretions  are  in  the  gall- 
bladder or  cystic  duct,  but  it  may  be  so  slight  as  to  only 
show  a  mere  doubtful  tinge  in  the  conjunctivae.  In  some 
doubtful  cases  of  so-called  '  spasms,'  as  in  other  manifesta- 
tions of  cholelithiasis,  it  may  be  of  importance  to  be  able  to 
discover  mere  traces  of  bile,  for  if  definitely  present  in  the 
blood  or  urine  it  would  render  the  diagnosis  of  cholelithiasis 
more  probable. 

The  method  suggested  by  Dr.  Hamel  (Medical  Press, 
October  15,  1902),  Assistant  of  the  Berlin  Medical  Clinic  of 
the  late  Professor  Gerhardt,  promises  to  be  of  considerable 
practical  value.  In  suspicious  cases,  he  advises  an  examina- 
tion of  the  blood-serum  of  the  patient.  He  fills  a  small 
capillary  tube  with  blood  from  a  puncture  in  the  lobe  of  the 
ear,  and  seals  it  at  both  ends.  After  standing  for  a  few  hours 
in  a  vertical  position  the  serum  separates  from  the  blood-clot, 
and  then  can  be  examined  against  the  light.  Normal  serum 
is  colourless,  whereas  the  slightest  trace  of  bile  is  revealed 
by  a  yellowish  tint,  varying  in  depth  with  the  degree  of 
saturation.     This  simple  test  should  be  useful  in  determining 


GALL-STONES,  OR  CHOLELITHIASIS  235 

many  obscure  points  in  the  action  of  bile-poisoning  upon  the 
human  system,  especially  when  the  bile  exists  in  minute 
quantities  in  the  circulation. 

The  identification  of  bile-pigments  in  the  urine  is  also  a 
clinical  detail  of  considerable  importance.  The  reaction 
usually  employed — that  introduced  by  Gmelin — is  open  to 
the  objection  that  on  the  addition  of  the  acid  to  albuminous 
urine  the  precipitate  of  albumin  obscures  the  play  of  colours. 
Moreover,  should  the  urine  under  examination  contain 
indican,  the  resulting  blue  coloration,  in  association  with  the 
yellow  tint  of  the  urine,  gives  a  green  tinge  calculated  to 
mislead.  Heller's  reaction,  on  the  other  hand,  is  not  very 
well  marked,  and  entails  the  use  of  chloroform,  which  com- 
plicates the  procedure.  Dr.  Baudouin,  of  Tours  {Medical 
Press,  December  10,  1902),  has  introduced  a  reaction  which, 
from  the  point  of  view  of  simplicity  and  precision,  appears 
to  possess  certain  advantages  over  those  in  common  use. 
He  employs  a  solution  of  fuchsine  (%  per  cent.).  If  2  or 
3  drops  of  the  fuchsine  solution  be  introduced  into  urine 
containing  bile,  it  immediately  develops  a  fine  orange  tint, 
in  marked  contrast  with  the  violet-red  of  the  test  solution. 
No  other  colouring  matter  of  urine  provokes  this  reaction, 
which  is  determined  by  very  minute  proportions  of  bile- 
pigment. 

Dr.  J.  W.  Duncan  (British  Medical  Journal,  February  14, 
1903)  says  the  methylene  blue  test  for  bile-pigment,  noticed 
in  the  British  Medical  Journal  for  October  25,  1902,  seems 
fairly  reliable  and  very  speedy.  The  methyl  colours  also 
give  reactions.  Methyl  blue  and  methyl  violet  give  each  a 
red.  Paul's  test — a  solution  of  methyl-aniline  violet — gives 
a  red.  Loeffler's  blue  solution,  containing  methylene  blue, 
gives  a  green.  It  is  likely  that  the  homologues  of  these 
colours  also  give  reactions.  The  green  with  Loeffler's  blue 
can  be  made  to  vanish  on  heating  and  reappear  on  cooling. 
Carbol  fuchsin,  1  part,  Loeffler's  blue  solution  and  dilute 
hydrobromic  acid,  each  2  parts,  heated  to  boiling  and  cooled, 
give  a  blue.  A  few  drops  of  this  to  2  inches  of  urine  in 
a  test-tube  give  green  in  jaundice  cases  and  blue  in  others. 
Heating  the  top  of  the  liquid  causes  vanishing  of  green  and 


236    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

blue,  while  a  fuchsin  colour  comes  in.  On  cooling,  the  green 
or  the  blue  comes  back. 

Another  test — a  '  ring  '  test — is  as  follows  :  Take  2  inches 
of  urine  in  a  test-tube,  and  shake  with  20  drops  of  dilute 
hydrobromic  acid,  and  then  run  on  the  top  about  J  inch  of 
spirit  of  nitrous  ether.  A  green  ring  is  seen  at  the  junction 
of  the  fluids.  Shaking  the  fluids  together  gives  a  green 
throughout.  Another  is  got  by  adding  a  drop  or  two  of  old 
sodium  nitroprusside  solution  to  Ehrlich's  bile-pigment  test, 
when  a  dirty  coffee-brown  is  got. 

The  so-called  diagnostic  operations  of  sounding  for  gall- 
stones and  aspiration  of  a  distended  gall-bladder  are  not 
only  futile,  but  dangerous ;  a  small  exploratory  incision  is 
safer  and  far  better,  whether  for  information  or  treatment. 

The  diagnosis  of  gall-stones  by  means  of  the  Rontgen  rays 
has  not  led  to  any  constant  or  even  promising  results,  except 
in  the  case  of  those  concretions  containing  lime  salts. 

The  following  account  from  the  Berlin  Klin.  Woch., 
May  13,  1902,  p.  513  (reproduced  in  the  Medical  Review, 
p.  460,  to  the  editor  of  which  I  am  indebted  for  permission 
to  copy  the  plates),  shows  that  the  method  may,  however,  be 
occasionally  useful. 

Oberst  and  others  have  doubted  the  possibility  of  taking 
skiagrams  of  gall-stones.  Professor  Beck  has  employed  the 
Rontgen  rays  in  ninety-seven  cases  of  suspected  biliary 
calculi,  and  found  slight  indications  of  their  presence  in  only 
two,  although  in  thirteen  their  existence  was  afterwards 
ascertained  by  cholecystotomy.  Subsequent  attempts  have, 
however,  been  more  successful.  In  each  case  several  skia- 
grams should  be  taken,  in  order  to  determine  the  most  suit- 
able length  of  exposure.  The  longer  the  exposure,  the  clearer 
the  outlines  of  the  liver  and  the  fainter  those  of  the  calculi. 
A  long  exposure  of  ten  minutes  should  be  tried  first,  then  a 
short  one  of  about  five  minutes.  The  tubes  employed  should 
be  capable  of  conducting  large  quantities  of  electricity,  and 
should  have  a  high  penetrating  power.  As  a  general  rule,  a 
tube  which,  with  a  16-inch  spark,  casts  a  grayish-black 
shadow  of  the  carpal  end  of  the  radius,  and  makes  the  soft 
parts  appear  almost  transparent,  is  suitable.     A  very  '  hard  ' 


PLATE  XXX, 


Fig.  6i.--  Gall-stones  in  situ, 


Fig.  62. — Various  Types  of  Gall-stones. 


To  face  p.  236.] 


PLATE  XXXI. 


Fig.  63. — Skiagram  of  Gall-stones. 


To  face  p.  236.] 


GALL-STONES,  OR  CHOLELITHIASIS  237 

— i.e.,  highly  evacuated — tube  emits  rays  which  completely 
penetrate  the  calculi  and  cast  no  shadow.  The  intestine 
should  be  previously  emptied,  and  the  patient  should  lie  face- 
downwards  with  a  cushion  under  the  clavicular  region,  in 
order  to  render  the  gall-bladder  as  prominent  as  possible. 
The  rays  should  strike  the  body  obliquely  at  an  angle  of 
45  to  55  degrees,  although  this  magnifies  the  stones  some- 
what. With  these  technical  precautions  Professor  Beck  has 
repeatedly  obtained  clear  skiagrams  of  biliary  calculi.  A 
negative  result  does  not  exclude  gall-stones,  even  after 
repeated  applications  of  the  rays,  but  a  positive  one  confirms 
the  diagnosis.  Fig.  61  is  a  reproduction  of  a  skiagram  show- 
ing gall-stones  in  situ  in  a  man  aged  thirty-seven.  There  are 
two  large  calculi  in  the  gall-bladder  ;  the  small,  non-faceted 
stone  probably  lies  in  the  cystic  duct,  and  the  three  with 
facets  are  in  the  intrahepatic  ducts.  After  cholecystotomy, 
however  carefully  the  gall-bladder  and  bile  passages  are 
explored  and  the  calculi  are  removed,  a  few  small  stones 
frequently  appear  later.  This  skiagram  explains  this  fact, 
and  at  the  same  time  proves  that  the  operation  of  chole- 
cystotomy is  preferable  to  that  of  cystendysis  with  immediate 
closure  of  the  gall-bladder. 

Professor  Beck  has  found  that  the  chemical  composition  of 
the  various  gall-stones  greatly  influences  their  demonstra- 
bility  by  skiagraphy.  He  placed  a  number  of  calculi  col- 
lected from  different  patients  under  the  abdomen  of  an 
adult  while  lying  face  downwards  and  then  applied  the  rays. 

(1)  Common  gall-stones  (Figs.  62  and  63,  No.  5)  consist  of 
a  hard  shell  with  a  soft  nucleus,  and  the  possibility  of  finding 
them  with  the  Rontgen  rays  depends  on  the  thickness  of  the 
external  layer.  (2)  Pure  cholesterin  stones  (Figs.  62  and  63, 
No.  2)  give  more  marked  shadows.  Lamellated  cholesterin 
stones  have  a  crystalline  centre  of  pure  cholesterin,  with  a 
green  or  colourless  surface  composed  of  bilirubin  and  bili- 
verdin  combined  with  chalk.  In  the  green  layers  carbonate 
of  calcium  is  present,  and  such  stones  are  readily  detected. 
(3)  Stones  composed  of  bilirubin  chalk  with  a  small  nucleus 
of  cholesterin  are  generally  solitary  or  occur  in  pairs.  They 
cast  very  dark  shadows  (Figs.  62  and  63,  No.  6).     (4)  Stones 


23S    DISEASES  OE  THE  GALL-BLADDER  AXD  BILE-DUCTS 

of  pure  bilirubin  or  bilihumin  with  chalk  are  very  rare,  but 
easily  demonstrable  (Figs.  62  and  63,  No.  9).  They  are 
gray  or  black,  and  have  a  metallic  lustre.  (5)  Small  stones 
of  pure  amorphous  or  crystalline  cholesterin  are  rare.  They 
somewhat  resemble  pearls,  have  a  small  nucleus  of  chalk  or 
bilirubin,  and  cast  fairly  distinct  shadows.  (6)  Stones  com- 
posed of  chalk,  whether  combined  with  carbonic  acid  or  bili- 
rubin, are  very  hard,  and  cast  very  dark  shadows. 

The  treatment  of  gall-stones  may  be  considered  under  the 
heads  preventive,  palliative,  and  radical.  The  first  two 
resolve  themselves  into  medical,  the  last  into  surgical, 
treatment. 

Medical  Treatment. 

The  preventive  treatment  of  cholelithiasis  is  chiefly  a 
matter  of  attention  to  diet,  exercise,  and  general  hygienic 
surroundings.  As  women  suffer  from  gall-stones  much  more 
frequently  than  men,  it  has  been  thought  that  their  mode 
of  dress,  especially  the  wearing  of  stays,  may  be  one  of  the 
causes  ;  but  probably  the  want  of  sufficient  exercise,  with 
constipation  and  rich  living,  its  frequent  concomitants,  is 
more  to  blame.  In  prescribing  prophylactic  measures  one 
would  recommend  rational  clothing  (which,  of  course, 
includes  the  avoidance  of  tight-lacing),  temperance  in  diet, 
warm  baths,  fresh  air,  and  regular  exercise.  In  regard  to 
diet,  more  depends  on  temperance  than  on  the  choice  or 
refusal  of  certain  foods.  In  giving  directions  on  diet, 
patients  may  with  advantage  be  told  to  avoid  overindul- 
gence in  sweet  and  starchy  foods  and  in  rich  dishes,  which 
tend  to  induce  dyspepsia.  Alcohol  should  only  be  taken  in 
moderation,  well  diluted,  and  with  food. 

In  accordance  with  views  expressed  in  considering  the 
causation  of  gall-stones,  either  a  sufficiency  of  albuminous 
food  in  the  shape  of  meat  or  game,  or  farinaceous  foods  con- 
taining a  fair  proportion  of  nitrogen,  should  be  taken.  If 
there  is  any  benefit  to  be  obtained  by  the  administration  of 
olive  oil,  the  use  of  butter  or  of  animal  fats,  taken  in  quanti- 
ties short  of  producing  dyspepsia,  should  have  a  similar  effect. 
Sir  Lauder  Brunton  gives  some  valuable  hints  on  treatment, 
and   shows   how  the  system   of  dieting   adopted  at    certain 


GALL-STONES,  OR  CHOLELITHIASIS  239 

watering-places,  when  combined  with  exercise  and  the 
administration  of  certain  diluent  beverages  (water  being  the 
essential  element),  has  very  beneficial  results.  It  is  a  very 
good  plan  to  recommend  patients  suffering  from  chole- 
lithiasis to  drink  a  tumblerful  of  the  natural  Carlsbad  water 
with  a  little  hot  water  before  breakfast,  and  a  tumblerful  of 
simple  hot  water  before  the  later  meals  ;  for  there  can  be 
little  doubt  that,  as  a  rule,  too  little  water  is  taken,  and  the 
inspissated  or  stagnant  bile  and  mucous,  if  not  removed, 
will  tend  in  the  long-run  to  form  concretions,  just  as  drains, 
if  not  flushed  from  time  to  time,  will  become  blocked  by 
the  deposition  of  solid  matter. 

Alkaline  saline  waters  (particularly  Carlsbad  water  taken 
hot  before  breakfast)  act  beneficially  by  stimulating  the  peri- 
stalsis of  the  digestive  tract,  and  so  increasing  the  flow  of 
blood  to  the  abdominal  organs.  In  the  peristalsis  the  bile 
passages  participate,  and  the  movement  of  the  bowel  acts  as  a 
form  of  massage,  while  the  diseased  mucous  membrane  benefits 
by  the  increased  flow  of  blood.  The  injection  of  large  quan- 
tities of  hot  water  into  the  rectum  serves  the  same  purpose. 

When  gall-stones  have  once  formed,  no  medicine,  so  far  as 
we  know,  can  dissolve  them  or  produce  any  material  benefit 
except  by  way  of  palliation.  Although  numerous  remedies 
have  been  vaunted  as  beneficial  in  the  dissolution  of  gall- 
stones, their  advocates  have  argued  as  if  the  stones  were  in  a 
test-tube,  forgetting,  apparently,  that  no  drug  can  reach  the 
concretions  save  by  a  very  circuitous  route  and  in  an 
extremely  diluted  form ;  thus,  benzoic  acid,  benzoate  of 
soda,  salicylic  acid,  turpentine,  ether,  chloroform,  and 
numerous  other  agents  reported  to  be  beneficial,  can  really 
have  no  material  effect.  We  would  not  for  a  moment  say, 
however,  that  rational  medical  treatment  may  not  relieve  the 
catarrh  of  the  gall-bladder  or  bile-ducts  generally  associated 
with  gall-stones  when  they  are  producing  symptoms,  and 
restrict  the  increase  of  gall-stones  already  formed,  or  prevent 
the  formation  of  new  ones,  and  thus  prove  reallv  curative  if 
the  patient  have  the  good  fortune  to  part  with  those  alreadv 
formed. 

The   experiments    of   Dr.    Brockbank   effectually    dispose 


240    DISEASES  OF  THE  GALL-BLADDER  AXD  BILE-DUCTS 

of  the  supposition  that  the  so-called  saline  cholagogues 
have  any  solvent  action  on  gall-stones  ;  for,  after  allowing 
concretions  to  stand  in  a  i  per  cent,  solution  of  the  various 
salts  for  fourteen  days  and  then  weighing  them,  he  found  that 
there  had  been  no  loss  of  weight.  Among  the  drugs  thus 
experimented  on  were  the  salicylate,  the  sulphate,  the  ben- 
zoate,  the  phosphate,  the  bicarbonate,  and  the  chloride  of 
soda,  sulphate  of  potash,  and  chloride  of  ammonium. 

Similar  experiments  with  olive  oil,  oleic  acid,  and  a  solu- 
tion of  sapo  animalis  yielded  far  different  results.  A  gall- 
stone placed  in  pure  olive  oil  lost  68  per  cent,  of  its  original 
weight  in  two  days,  and  then  broke  up  into  small  pieces. 
With  pure  oleic  acid  a  similar  result  followed  in  a  much 
shorter  space  of  time,  a  small  gall-stone  disappearing  in 
twenty-four  hours,  and  a  larger  one,  after  losing  63  per  cent, 
of  its  weight  in  two  days,  broke  up  into  small  fragments  in 
four  days.  The  effect  of  a  solution  of  animal  soap  on  the 
concretion  is  remarkable :  after  standing  for  a  few  hours  in  a 
5  per  cent,  solution  a  gall-stone  becomes  coated  with  a  bluish- 
white,  filmy  material,  and  in  time  the  solid  matter  becomes 
viscid.  In  view  of  the  fact  that  the  administration  of  olive 
oil  is  said  to  have  a  curative  effect  in  cholelithiasis,  these 
experiments  are  interesting  ;  but,  as  there  is  not  the  slightest 
evidence  that  the  oil  can  reach  the  gall-stone  in  the  gall- 
bladder or  cystic  duct,  there  must  be  some  other  than  direct 
solvent  action  to  explain  the  beneficial  effect — indeed,  that 
such  an  effect  takes  place  is  doubted  by  some  observers,  and 
requires  more  direct  proof  before  it  can  be  accepted. 

An  explanation  of  what  occurs  is  offered  by  Dr.  Brockbank 
in  his  book  ('  On  Gall-stones,'  E.  M.  Brockbank  ;  London, 
1896)  :  '  Another  explanation  of  the  reported  disappearance 
of  the  gall-stones  after  large  doses  of  oil  may  be  derived  from 
the  action  of  soap  and  fats  on  cholesterin.  A  digested  fat 
passes  into  the  circulation  from  the  alimentary  canal  in  three 
forms — as  unchangeable  fat,  as  the  corresponding  fatty  acid, 
and  as  soap.  All  occur  normally  in  the  bile,  and  the  amount 
present  in  the  bile  increases  with  the  amount  of  fat  taken  in 
the  diet.  Oil,  fatty  acids,  and  soaps  all  dissolve  cholesterin 
readily,  and  break  up  a  gall-stone.     If,  then,  the  oil,  fatty 


GALL-STONES,  OR  CHOLELITHIASIS  241 

acid,  and  soap  appear  in  the  bile  in  increased  amount  after 
large  doses  of  oil,  it  is  very  probable  that  the  gall-stone  is 
attacked  by  them,  especially  by  the  soap,  and  in  time  is  dis- 
solved or  so  reduced  in  bulk  as  to  be  enabled  to  pass  out  into 
the  duodenum.' 

We  have  tried  olive  oil  in  large  doses  in  many  cases,  and 
cannot  say  that  we  have  seen  much  good  to  result  from  its 
employment,  unless,  perhaps,  in  one  case  of  impacted  calculi 
in  the  common  duct,  where  an  operation  was  performed  after 
the  olive-oil  treatment  had  been  tried  for  some  weeks.  The 
gall-stones  were  then  found  to  yield  more  readily  than  usual 
to  the  pressure  of  the  finger  and  thumb,  as  if  the  treatment 
had  lessened  their  consistency. 

The  oil  may  be  administered  either  by  the  mouth  or  by  the 
rectum  ;  in  either  case  from  3  to  10  ounces  should  be  given 
daily.  It  is  not  readily  taken  except  with  food,  and  even 
then  it  is  apt  to  give  rise  to  dyspepsia. 

Dr.  Goodhart  (British  Medical  Journal,  January  30,  1892) 
gives  an  account  of  five  cases  of  probable  cholelithiasis  in 
which  olive  oil  had  been  administered  with  apparent  benefit. 
He  remarks  :  '  With  reference  to  the  results,  I  wish  to  say 
that  it  is  obvious  that  I  cannot  claim  for  these  cases  any- 
thing more  than  a  suspicion  in  favour  of  the  value  of  the 
administration  of  oil.  In  no  one  of  the  cases  have  gall- 
stones been  proved  to  have  passed,  and  in  none  of  the  cases 
has  improvement  been  so  immediate  that  effect  and  cause 
certainly  go  together.' 

Dr.  Kishkin's  experiments  appear  to  show  how  a  mistaken 
idea  of  its  good  effects  has  arisen.  The  supposed  calculi 
which  were  parted  with  were  found  to  consist  of  oleic, 
palmitic,  and  margaric  acids  combined  with  lime,  and 
similar  concretions  could  be  produced  at  any  time  by  giving 
olive  oil  to  any  persons  suffering  from  scanty  biliary  secre- 
tion. No  true  gall-stones  were  ever  found  in  the  motions 
after  the  olive-oil  treatment. 

The  administration  of  eunatrol  (oleate  of  soda)  in  the 
form  of  pill  has  appeared  to  do  gcod  in  some  cases  that 
either  declined  or  were  unfit  for  operation.  The  action  of 
eunatrol  is,  we  presume,  like  that  of  olive  oil. 

16 


242    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Belladonna  has  been  said  to  have  a  specific  action  in 
cholelithiasis,  and  it  is  readily  conceivable  that,  if  a  small 
concretion  were  passing  along  the  ducts,  by  its  specific  action 
on  involuntary  muscular  fibre  this  drug  might  aid  in  its 
expulsion.  But  we  cannot  agree  with  a  medical  writer  who 
says  that  a  pill  containing  J  grain  of  extract  of  belladonna 
and  i  grain  of  podophyllin  resin  is  a  remedy  as  nearly 
approaching  a  specific  as  it  is  possible  to  obtain. 

Massage  found  a  strong  advocate  in  the  late  Dr.  George 
Harley,  who  said  :  '  For,  without  doubt,  perseverance  and 
opportunity  will  in  the  end  enable  them  (the  operators)  to 
discover  gall-bladders  equally  as  readily  as  the  trained 
fingers  of  the  expert  do,  and  that,  too,  even  through 
abdominal  parietes  so  thick  that  the  untrained  hands  can- 
not do  so  much  as  make  out  the  boundary  of  the  solid  liver 
through  them.  While,  again,  they  will  ultimately  find  that 
they  will  be  able  to  extrude  small  impacted  biliary  concre- 
tions, be  they  in  the  shape  of  sand,  gravel,  or  stones,  from 
the  bile-ducts  into  the  duodenum  with  as  much  safety  and 
certainty  as  they  can  pass  a  catheter  through  a  stricture  into 
a  human  urinary  bladder.  At  the  same  time,  for  the  sake  of 
the  patient's  welfare  as  well  as  their  own  reputation,  they 
must  never  forget  to  be  as  careful  in  the  mode  of  operative 
procedure  in  the  one  case  as  in  the  other,  as  neither  operation 
is  invariably  unattended  with  danger.  This  is  especially  the 
case  when  the  manipulative  operation  has  been  unfortunately 
delayed  till  the  gall-stones  have  grown  large  and  hard,  and, 
on  account  of  the  prolonged  pressure,  begun  to  ulcerate 
through  the  tissues  they  have  long  pressed  against.' 

It  is  scarcely  necessary  to  do  more  than  draw  attention  to 
the  description  of  the  gall-stones  at  the  beginning  of  this 
chapter  and  to  the  many  changes  frequently  present  in  the 
gall-bladder  and  bile-ducts,  in  order  to  point  out  how  futile 
— nay,  more,  how  injurious — massage  must  be  in  many 
cases,  however  skilfully  performed  ;  for  not  only  is  it  un- 
likely, but  in  by  far  the  greater  number  of  cases  it  is  utterly 
impossible  that  the  concretions  can  be  forced  through 
passages  so  narrow  as  we  know  the  cystic  and  common 
ducts  to  be. 


GALL-STONES,  OR  CHOLELITHIASIS  243 

We  can  only  say  that  were  we  the  subjects  of  chole- 
lithiasis we  would  not  submit  to  massage,  nor  could  we 
conscientiously  recommend  it  to  others.  Although  it  may  aid 
the  expulsion  of  small  calculi,  it  is  impossible  to  diagnose  the 
absence  of  large  ones  or  to  know  the  exact  condition  of  the 
ducts,  which  may  possibly  be  ruptured  by  manipulation. 

During  a  gall-stone  attack  relief  is  urgently  demanded. 
At  times  the  drinking  of  a  pint  of  water  as  hot  as  it  can  be 
taken,  especially  if  combined  with  the  application  of  hot 
fomentations  over  the  region  of  the  liver,  will  assuage  the 
pain ;  at  other  times  the  administration  of  3c  drops  of 
spiritus  etheris  in  J  ounce  of  chloroform-water  every  quarter 
of  an  hour  for  three  or  four  doses  will  answer  the  same 
purpose.  In  some  cases  aspirin  in  5  or  10  grain  doses,  and 
repeated  in  an  hour  or  two  if  required,  may  prove  of  service. 
In  many  cases,  however,  the  only  satisfactory  remedy  is  a 
morphia  injection. 

Surgical  Treatment. 

After  medical  treatment  has  been  fairly  and  fully  tried  and 
failed,  all  are  now  agreed  that  surgical  measures  should  be 
resorted  to. 

While  cholecystotomy  is  generally  recognised  as  the  opera- 
tion to  be  aimed  at  in  the  treatment  of  affections  of  the  gall- 
bladder or  bile-ducts,  especially  in  cholelithiasis,  it  is  often 
impossible  to  say  what  operation  will  have  to  be  done  until 
the  abdomen  is  opened. 

The  indications  for  operating  would  seem  to  be  as 
follows  : 

1.  In  frequently  recurring  biliary  colic  without  jaundice, 
with  or  without  enlargement  of  the  gall-bladder. 

2.  In  enlargement  of  the  gall-bladder  without  jaundice, 
even  if  unaccompanied  by  great  pain. 

3.  In  persistent  jaundice  ushered  in  by  pain,  and  where 
recurring  pains,  with  or  without  ague-like  paroxysms,  render 
it  probable  that  the  cause  is  gall-stones  in  the  common 
duct. 

4.  In  empyema  of  the  gall-bladder. 

5.  In  peritonitis,  starting  in  the  right  hypochondrium. 

16 — 2 


244    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

6.  In  abscess  around  the  gall-bladder  or  bile-ducts,  whether 
in  the  liver  or  under  or  over  it. 

7.  In  some  cases  where,  although  gall-stones  may  have 
passed,  adhesions  remain  and  prove  a  source  of  pain  and 
illness. 

8.  In  fistula  discharging  mucus  or  muco-pus. 

9.  In  certain  cases  of  chronic  jaundice  with  distended 
gall-bladder  dependent  on  some  obstruction  in  the  common 
duct,  although  the  suspicion  of  malignancy  be  entertained. 
In  such  cases  the  increased  risk  must  be  borne  in  mind, 
as  malignant  disease  may  be  the  cause  of  the  obstruction, 
and  operation  in  such  cases  is  attended  with  greater  danger 
than  ordinary. 

10.  In  phlegmonous  cholecystitis  and  in  gangrene,  if  the 
case  be  seen  and  recognised  at  a  sufficiently  early  stage  of 
the  disease. 

11.  In  gunshot  injury  or  in  stab-wound  over  the  region  of 
the  gall-bladder. 

12.  In  suspected  rupture  of  the  gall-bladder  without 
external  wound. 

13.  In  some  cases  of  chronic  catarrh  of  the  gall-bladder  or 
bile-ducts. 

14.  In  infective  and  in  suppurative  cholangitis. 

15.  In  certain  solid  tumours  of  the  gall-bladder  where 
there  is  no  evidence  of  secondary  growths  in  the  liver. 

16.  In  certain  cases  of  biliary  fistula  if  it  be  thought  that 
the  cause  of  obstruction  may  possibly  be  removed. 

17.  In  acute,  subacute,  or  chronic  pancreatitis  due  to  gall- 
stone obstruction  and  secondary  infection. 

Diagnostic  Operations. 

Of  the  operative  measures  undertaken  for  diagnosis,  sound- 
ing and  aspiration  of  the  gall-bladder  must  be  referred  to. 
The  so-called  '  sounding  for  gall-stones,'  either  by  means  of 
a  probe  passed  through  a  cannula,  or  by  the  fine  needle  of  an 
aspirator,  is  both  uncertain  and  dangerous,  and  may  more 
safely  be  replaced  by  a  small  exploratory  incision,  which  can 
be  extended  for  treatment   if  required.     If  the  patient   be 


GALL-STONES,  OR  CHOLELITHIASIS  245 

thought  too  feeble  to  bear  a  general  anaesthetic,  this  opera- 
tion may  be  done  under  cocaine. 

Aspiration  of  a  distended  gall-bladder  through  the  un- 
opened abdomen,  though  apparently  a  simple  procedure,  is 
not  unattended  with  danger,  death  having  followed  in  more 
than  one  instance.  Murphy  says  it  is  fatal  in  25  per  cent. 
It  is  only  in  very  exceptional  cases  that  it  can  do  any  good. 

It  is  infinitely  preferable  to  make  a  small  exploratory 
incision,  then  to  empty  the  gall-bladder  by  the  aspirator,  and 
afterwards  to  explore  the  bile  passages  with  the  fingers.  If, 
however,  aspiration  without  exploration  be  decided  on,  a 
small  needle  should  be  used,  and  the  cyst  emptied  as  far  as 
possible,  in  order  that  intracystic  tension  may  not  lead  to 
extravasation  through  the  needle  puncture. 

General  Considerations  bearing  on  Operations  on  the  Gall- 
bladder and  Bile-ducts. 

While  cholecystotomy  is  generally  recognised  as  the 
operation  to  be  aimed  at  in  the  treatment  of  affections  of  the 
gall-bladder  and  bile-ducts,  it  is  often  impossible  to  say  what 
operation  will  have  to  be  done  until  the  abdomen  is  opened 
and  the  exact  state  of  affairs  made  out,  for  a  contracted  or 
dilated  gall-bladder,  a  suppurating  or  merely  a  distended 
viscus,  concretions  in  the  gall-bladder  or  cystic  or  common 
ducts,  the  condition  of  the  surrounding  organs,  the  presence 
or  absence  of  adhesions,  and  a  host  of  other  conditions,  will 
all  influence  the  subsequent  action  of  the  surgeon,  who 
always  begins  the  operation  as  an  exploratory  one,  the  subse- 
quent steps  depending  on  the  nature  of  the  disease. 

No  surgeon  should  attempt  the  removal  of  gall-stones  unless 
he  is  prepared  for  any  of  the  various  operations  on  the  biliary 
passages,  such  as  choledochotomy  or  cholecystectomy,  as  it 
is  almost  impossible  to  say  beforehand  what  may  be  required 
until  the  ducts  have  been  explored  by  the  fingers  and  the  condi- 
tion of  the  affected  viscera  ascertained  ;  no  operation  should, 
as  a  rule,  be  concluded  until  it  is  clearly  made  out  that  the 
ducts,  including  the  hepatic  and  common,  are  quite  free  from 
concretions,  otherwise  disappointment  and  dissatisfaction  are 


246    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

certain  to  follow.  Since  in  the  majority  of  cases,  then,  an 
operation  for  gall-stones  is  in  the  first  place  simply  explora- 
tory, the  actual  operation  on  the  gall-bladder  or  bile-ducts 
being  only  determined  by  the  condition  found  when  the 
abdomen  is  opened,  it  may  be  well  for  us  first  to  consider  a 
simple  abdominal  section  in  the  gall-bladder  region. 

Preparation  for  Operation. 

It  may  be  convenient  here,  before  considering  the  operation 
itself,  to  give  some  of  the  details  carried  out  in  my  operative 
work  generally,  especially  as  they  apply  to  the  operations 
about  to  be  described. 

First,  as  to  the  room  in  which  the  operation  has  to  be 
performed.  Any  ordinary,  well-cleaned  room,  having  high 
windows  so  as  to  give  good  top  light,  answers  almost  as  well 
as  an  operating  theatre.  There  is,  of  course,  an  advantage 
in  having  electric  light,  but,  as  I  shall  show,  the  operation  I 
now  perform  on  the  bile  passages  is  done  close  to  the  surface 
with  few  exceptions,  not  as  formerly  at  a  great  depth,  which 
necessitated  a  special  electric  lamp,  and  always  a  very  good 
vertical  or  high  oblique  light. 

The  advantage  of  operating  in  a  hospital  or  surgical  home 
is  that  the  surgeon,  or  his  house-surgeon  or  assistant,  is 
responsible  not  only  for  the  operation,  but  also  for  the  after- 
attendance,  a  matter  almost  as  important  as  the  operation 
itself.  Moreover,  the  surgeon  can  do  his  work  better,  and 
with  greater  confidence,  where  he  is  accustomed  to  operate, 
and  where  he  is  confident  that  all  his  directions,  before,  at 
the  time,  and  subsequently,  will  be  carried  out  to  the 
letter. 

In  this  matter  of  where  the  operation  should  be  done,  the 
surgeon  who  has  to  do  the  operation  ought  to  make  the 
selection,  and  the  patient  should  abide  by  the  decision  with 
the  full  confidence  that  the  operator  will  select  the  place 
where  he  can  do  his  work  to  the  best  advantage  of  the 
patient. 

I  have  seen  several  unsatisfactory  cases  in  which  patients 
insisted  on  having  operations  performed  in  their  own  homes, 


GALL-STONES,  OR  CHOLELITHIASIS  247 

which  were  utterly  unsuitable  for  such  a  purpose.  These 
cases  would  in  all  probability  have  done  well  had  they  been 
in  a  surgical  home,  where  the  complications  causing  the 
trouble  could  have  had  immediate  and  skilful  attention. 

The  surgeon  ought  also  to  be  helped  by  his  ordinary 
assistant  in  all  serious  operations  such  as  I  am  about  to 
describe,  for  a  stranger,  no  matter  how  skilful,  can  never 
accommodate  himself  immediately  to  the  needs  of  the 
operator,  and  it  must  be  remembered  that  surgery  is  a  fine 
art  that  can  only  be  carried  out  with  the  greatest  perfection 
under  circumstances  that  are  favourable  to  the  artist. 

The  selection  of  the  anaesthetist  should  also  be  with  the 
operator,  for  with  a  competent  anaesthetist  the  surgeon  can 
devote  the  whole  of  his  mind  to  his  own  part  of  the  work  in 


Fig.  64. — Gall-stone  Scoop. 

hand,  without  having  his  attention  diverted  to  make  sugges- 
tions concerning  the  anaesthetic. 

With  regard  to  instruments,  a  gall-stone  scoop  is  the  only 
special  appliance  I  employ,  and  all  the  instruments  are  boiled 
for  half  an  hour  before  being  used. 

My  sutures  and  ligatures  are  of  formalin  catgut  prepared 
by  the  xylol  process,  which  I  described  in  the  British  Medical 
Journal  of  September  27,  p.  974.  No.  '  00 '  size  is  used  for 
ligatures,  and  No.  '  o  '  size  for  sutures ;  they  are  strong  and 
reliably  aseptic.  Since  the  introduction  of  celluloid  thread, 
I  have  given  up  the  use  of  silk  for  sutures,  as  the  former  is 
much  stronger,  ties  with  a  very  firm  knot,  and  is  easily 
sterilized  by  boiling.  As  it  is  not  absorbable,  I  only  employ 
it  for  the  outer  or  serous  suture  in  stitching  the  incision  in 
the  duct  in  choledochotomy,  and  for  this  purpose  the  '  00  ' 
green  chromic  catgut  prepared  by  the  xylol  process  answers 


248    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

equally  well,  as  it  does  not  become  absorbed  before  the 
second  or  third  week.  As  showing  the  disadvantage  of  non- 
absorbable sutures,  a  case  came  under  my  notice  in  which  a 
silk  suture  used  in  a  choledochotomy  formed  the  nucleus  of 
another  gall-stone,  which  fortunately  passed  without  further 
operation. 

As  sponges  I  employ  sterilized  gauze  swabs,  but  for  keep- 
ing the  viscera  out  of  the  way  I  use  flat  marine  sponges,  than 
which  I  find  nothing  to  answer  so  well.  The  area  of  operation 
is  surrounded  by  dry  sterilized  towels,  sterilized  by  dry, 
superheated  steam  for  half  an  hour. 

My  assistant,  dressers,  and  nurses  all  wear  boiled  rubber 
gloves,  though  personally  I  do  not,  unless  I  have  just  had  a 
septic  case  to  operate  on,  as  I  find  they  impair  my  sense  of 
touch  and  cause  some  delay  ;  but  I  take  especial  care  to  scrub 
and  wash  several  times  before  operating,  and  near  the  oper- 
ating table  I  keep  a  bowl  of  i  in  2,000  mercury  biniodide 
solution,  in  order  to  lave  my  hands  from  time  to  time  during 
the  course  of  the  operation.  The  instruments  are  used  out 
of  a  1  in  40  absolute  phenol  solution,  and  the  sponges  out  of 
1  in  2,000  biniodide  solution,  but  they  are  wrung  quite  dry 
before  being  used.  Doubtless  an  ordinary  saline  solution 
would  answer  equally  well  for  instruments  and  sponges,  but 
I  think  not  for  the  hands.  The  ligatures  are  used  out  of  a  1 
in  40  phenol  solution  in  spirit,  in  which  they  are  also  stored. 

The  patient  is  prepared  by  having  an  aperient  given,  so  as 
to  secure  the  bowels  being  moved  the  day  before  operation, 
and  an  enema  is  given  the  evening  before,  if  the  operation  is 
to  take  place  early  the  next  morning.  If  there  is  any  feeble- 
ness of  pulse,  5  minims  of  liq.  strychnia  are  given  subcu- 
taneously  on  the  afternoon  and  evening  of  the  day  before 
operation,  and  10  minims  as  soon  as  the  operation  has  begun. 
Should  there  be  chronic  jaundice  or  a  tendency  to  haemor- 
rhage, calcium  chloride  is  given  ;  for  although  there  is  a 
greater  tendency  to  bleeding  in  chronic  jaundice  from  pan- 
creatic disease  than  when  jaundice  is  due  to  gall-stone 
obstruction,  I  think  there  can  be  no  doubt  that  in  all  cholaemic 
conditions  the  blood  becomes  so  altered  that  the  coagulability 
becomes   seriously   diminished,    and    these    factors    demand 


GALL-STONES,  OR  CHOLELITHIASIS  249 

serious  attention  before  any  operation  is  undertaken  in  cases 
of  common  duct  cholelithiasis. 

The  skin  of  the  patient  over  the  operation  area  is  prepared 
the  day  before  by  thoroughly  washing  with  soft  soap,  or  some 
soap,  not  necessarily  antiseptic,  that  will  give  a  good  lather  ; 
if  needful,  shaving  is  then  done,  and  the  whole  area  is  gently 
rubbed  with  benzine.  A  dressing  of  lint,  wet  with  1  in  40 
carbolic  solution  in  water,  is  then  applied,  and  over  this  oil- 
skin or  gutta-percha  tissue.  The  dressing  is  changed  early  the 
next  morning,  and  the  skin  is  thoroughly  washed,  so  as  to  clear 
away  all  loose  and  sodden  epithelium,  after  which  another  1  in 
40  dressing  is  applied,  to  be  removed  on  the  operating-table. 

If  the  patient  is  feeble,  a  pint  of  normal  saline  solution 
with  an  ounce  of  brandy  is  given  a  short  time  before  the 
operation.  As  shock  is  intensified  by  exposure  to  cold,  my 
patients  are  always  enveloped  in  cotton-wool,  which  is  con- 
veniently done  by  making  a  suit  of  gamgee  tissue,  that  can  be 
readily  run  together  by  the  nurses  in  an  hour  or  two  the  day 
before  operation.  When  operating  in  a  theatre  I  employ  a 
heated  table,  but  elsewhere  indiarubber  hot-water  bottles 
around  the  patient  take  its  place.  It  will  be  found  that  a  firm 
sand-bag  about  18  inches  long  by  6  inches  wide  and  3J  inches 
deep,  covered  with  flannel,  and  placed  on  the  operating-table 
at  the  liver  level,  will  push  the  spine  forward,  and  with  it  the 
liver  and  bile-ducts,  so  that  the  common  and  hepatic  ducts 
are  brought  several  inches  nearer  to  the  surface.  By  opening 
out  the  costal  angle  and  tending  to  make  the  intestines  slip 
down  from  the  liver,  it  acts  like  the  Trendelenburg  position 
in  pelvic  surgery. 

Though  this  method,  until  I  drew  attention  to  it,  does  not 
seem  to  have  been  employed  by  others,  I  can,  from  ample 
experience,  speak  well  of  its  great  utility. 

Operation. 

Whereas  I  used  formerly  to  make  a  vertical  incision  through 
the  linea  semilunaris,  I  now  always  make  my  incision  over 
the  middle  of  the  right  rectus  in  a  line  parallel  with  its 
fibres,   which    are    then    separated   by   the    finger,  the  pos- 


250    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

terior  sheath  of  the  rectus   and  peritoneum  being  divided 
together.      Where  the  gall-bladder  is  distended  and  there 
is  no  jaundice,  a  small  incision  of  2  or  3  inches  only  may 
be    required  ;    but   when   it    is    necessary  to  explore   either 
the  hepatic,  common,  or  deeper  part  of  the  cystic  duct,  in- 
stead of  prolonging  the  incision  downwards,  as  was  formerly 
done,  I  now  carry  it   upwards  in  the  interval  between  the 
ensiform  cartilage  and  the  right  costal  margin  as  high  as 
possible,  thus  exposing  the  upper  surface  of  the  liver  very 
freely.     It  will  be  found  that  by  lifting  the  lower  border  of 
the  liver  in  bulk  and  rotating  it  (if  needful,  first  drawing  the 
organ  downwards  from  under  cover  of  the  ribs),  the  whole  of 
the  gall-bladder  and  the  cystic  and  common  ducts  are  brought 
quite  close  to  the  surface  ;  and  as  the  gall-bladder  is  usually 
strong  enough,  my  assistant  can  take  hold  of  it  with  his  fingers 
or  forceps,  and  by  gentle  traction  can  keep  the  parts  well 
exposed,  at  the  same  time  that,  by  means  of  his  left  hand 
with  a  flat  sponge  under  it,  he  retracts  the  left  side  of  the 
wound  and  the  viscera,  which  would  otherwise  fall  over  the 
common  duct  and  impede  the  view. 

It  will  now  be  observed  that,  instead  of  the  gall-bladder 
and  cystic  duct  making  a  considerable  angle  with  the  common 
duct,  an  almost  straight  passage  is  found  from  the  fundus  of 
the  gall-bladder  to  the  entrance  of  the  bile-duct  into  the 
duodenum,  and  if  adhesions  have  been  thoroughly  separated 
the  surgeon  has  immediately  under  his  eye  the  whole  length 
of  the  ducts,  with  the  head  of  the  pancreas  and  the  duo- 
denum. So  complete  is  the  exposure  that,  if  needful,  the 
peritoneum  can  be  incised  over  the  free  border  of  the  lesser 
omentum,  and  the  common  duct  separated  from  the  hepatic 
artery  and  portal  vein,  but  this  is  not  necessary  except  where 
a  growth  or  glands  have  to  be  excised.  The  surgeon,  whose 
hands  are  both  free,  can  now  deal  with  the  gall-bladder, 
cystic,  common,  or  hepatic  ducts  quite  easily ;  for  example, 
with  his  left  finger  and  thumb  he  can  so  manipulate  the 
common  or  cystic  duct  as  to  render  prominent  any  concre- 
tions, which  can  be  directly  cut  down  on,  the  edges  of  the 
opening  in  the  duct  being  caught  by  pressure  forceps.  The 
assistant  can  now  take  hold  of  the  forceps  with  his  left  hand, 


GALL-STONES,  OR  CHOLELITHIASIS  251 

as  they  with  the  sponge  will  form  a  sufficient  retractor,  since 
the  duct  is  so  near  the  surface.  When  the  duct  is  incised 
there  is  usually  a  free  flow  of  bile,  which,  it  must  be  remem- 
bered, is  probably  infective ;  but  by  inserting  a  sponge  in  the 
kidney  pouch,  and  rapidly  mopping  up  the  bile  as  it  flows  by 
means  of  sterilized  gauze  pads,  any  soiling  of  surrounding 
parts  is  avoided,  and,  if  thought  necessary,  the  bulk  of  the 
infected  bile  can  be  drawn  off  by  the  aspirator  either  from  the 
gall-bladder  or  from  the  common  duct  above  the  obstruction 
before  the  incision  into  the  bile  passages  is  made. 

After  removing  all  obvious  concretions,  the  fingers  are 
passed  behind  the  duodenum  and  along  the  course  of  the 
hepatic  ducts,  to  feel  if  other  gall-stones  are  hidden  there  ; 
and  when  the  common  duct  has  been  incised,  a  gall-stone 
scoop,  the  only  special  instrument  I  use,  is  passed  into  the 
primary  division  of  the  hepatic  duct  in  the  liver,  and  down 
to  the  duodenal  orifice  of  the  common  bile-duct,  and  if 
thought  necessary,  to  insure  the  opening  into  the  duodenum 
being  patent,  a  long  probe  is  passed  into  the  bowel. 

The  incision  into  the  bile-duct,  if  one  has  been  made,  is 
now  closed  by  an  ordinary  curved,  round  needle,  held  in  the 
fingers  without  any  needle-holder,  a  continuous  catgut 
suture  being  used  for  the  margins  of  the  duct  proper, 
and  a  continuous  fine  green  catgut  or  spun  celluloid  thread 
being  employed  to  close  the  peritoneal  edges  of  the  duct. 

Where  the  gall-bladder  is  contracted  and  the  pancreas  is 
indurated  and  swollen  from  chronic  pancreatitis,  and  likely 
to  exert  pressure  for  a  time  on  the  common  duct,  I  insert  a 
drainage-tube  directly  into  the  duct,  passing  it  upwards  into 
the  hepatic  duct,  and  closing  the  opening  around  it  by  a  cat- 
gut stitch,  which  will  hold  for  about  a  week ;  but  where  this 
is  not  done,  and  the  size  of  the  gall-bladder  will  permit  it,  I 
usually  fix  a  drainage-tube  into  the  fundus  of  the  gall-bladder 
in  the  same  way,  as  this  drains  away  all  infected  bile,  and 
avoids  pressure  on  the  newly-sutured  opening  in  the  duct. 

So  easy  is  it  to  remove  impacted  stones  after  this  method 
of  exposure  that  I  now  never  spend  a  long  time  in  manipula- 
ting stones  impacted  deeply  even  in  the  cystic  duct,  but  at 
once  incise  the  duct,  remove  the  concretions,  and  close  the 


252    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

opening,  without  damaging  the  duct  by  much  pressure  and 
prolonged  manipulation.  It  is  just  as  easy  to  incise  the 
hepatic  duct  where  that  is  necessary  or  advisable.  Although 
there  is  seldom  any  fear  of  leakage  or  infection,  yet  where 
the  ducts  have  been  incised  and  extensive  adhesions 
separated,  there  is  usually  some  tendency  to  pouring  out 
of  fluid  in  the  first  few  hours.  I  therefore  generally  insert  a 
gauze  drain  through  a  split  drainage-tube,  bringing  it  out  by 
the  side  of  the  gall-bladder  drain.  This  is  usually  removed 
within  twenty-four  hours. 

The  wound  is  closed  by  continuous  catgut  sutures,  first  to 
peritoneum  and  deep  rectus  sheath,  and  next  to  the  anterior 
rectus  sheath.  Lastly,  the  skin  margins  are  brought  together 
by  means  of  a  few  uninterrupted  silkworm-gut  sutures 
inserted  quite  an  inch  from  the  line  of  incision,  and  brought 
out  an  inch  beyond  the  incision  on  the  other  side,  so  as  to 
allow  the  edges  to  fall  together  without  tension,  thus  securing 
union  by  first  intention. 

To  those  having  little  experience  in  these  operations,  the 
modifications  I  have  employed  may  seem  trivial,  but  to  those 
who  have  experienced  the  difficulties  of  the  ordinary  opera- 
tion of  removing  gall-stones  from  a  contracted  gall-bladder 
or  from  the  cystic  or  common  ducts,  I  feel  sure  the  method 
I  have  described,  which  enables  the  whole  of  the  bile 
passages  to  be  dealt  with  as  a  straight  tube  close  to  the 
surface,  will  be  sufficiently  appreciated. 

In  these  operations  I  employ  forcipressure  for  the  imme- 
diate arrest  of  haemorrhage,  but  I  find  it  is  more  satisfactory 
also  to  ligature  all  the  bleeding-points,  as  in  jaundiced  cases 
the  compressed  and  unligatured  vessels  are  apt  to  bleed  sub- 
sequently and  to  lead  to  complications  that  are  avoidable  by 
careful  hasmostasis.  For  the  same  reason  I  prefer  to  divide 
and  ligature  firm  visceral,  especially  hepatic,  adhesions,  where 
that  is  practicable,  rather  than,  as  formerly,  to  separate  them 
with  the  finger  or  tear  them  through. 

If  the  liver  be  slightly  torn  in  separating  adhesions,  the 
bleeding  must  be  carefully  arrested  before  the  abdomen  is 
closed.  Sponge  pressure  is  usually  sufficient  if  the  laceration 
be  small,  and  this  may  be  made  more  efficient  by  using  at 


GALL-STONES,  OR  CHOLELITHIASIS  253 

the  same  time  a  solution  of  adrenalin  ;  but,  if  the  laceration 
be  extensive,  deep  catgut  sutures,  applied  by  means  of  a 
round  intestinal  needle,  will  usually  accomplish  the  desired 
effect  ;  or,  this  failing,  gauze  pressure,  the  plug  being  left  in 
until  it  becomes  loose,  will  be  certain  to  answer. 

Nothing  can  be  simpler  than  an  ordinary  cholecystotomy 
with  a  distended  gall-bladder,  or  even  with  a  gall-bladder  of 
ordinary  size,  where  a  small  incision  suffices  to  expose  the 
sac,  which  is  emptied  by  the  aspirator.  The  collapsed  sac  is 
then  brought  through  the  wound  and  surrounded  by  sterilized 
gauze ;  it  is  then  incised  through  the  point  where  the  needle 
was  inserted,  and  through  the  wound  in  the  fundus  the  gall- 
stone scoop  is  inserted  and  all  gall-stones  are  removed,  a 
probe  or  the  finger  being  employed  to  prove  the  ducts  clear. 
A  firm  rubber  tube,  much  firmer  than  the  drainage-tubes 
ordinarily  sold,  is  then  inserted  from  J  inch  to  1  inch  into 
the  gall-bladder,  the  edges  of  the  incision  being  drawn  firmly 
around  it  by  a  catgut  purse-string  suture,  which  is  tied  and 
cut  short,  the  drain  being  fixed  in  position  by  a  catgut  suture 
which  transfixes  the  tube  and  the  edges  of  the  incision  in  the 
gall-bladder.  The  edges  of  the  incision  in  the  gall-bladder 
are  then  fixed  to  the  aponeurosis  by  three  or  four  catgut 
stitches,  but  never  to  the  skin,  unless  a  permanent  biliary 
fistula  is  intended.  This  tube,  which  is  sufficiently  long  to 
pass  into  a  bottle  by  the  side  of  the  patient,  drains  all  the 
bile  away  from  the  wound,  and  by  the  time  the  catgut  has 
dissolved,  the  wound  will  have  healed  by  first  intention, 
except  where  the  tube  was,  and  that  part  heals  by  granulation 
within  the  next  week  or  two  if  the  ducts  are  clear. 

The  following  is  an  example  out  of  mam-,  of  a  simple 
cholecystotomy : 

Mrs.  C,  aged  forty-one,  was  admitted  to  the  Leeds  In- 
firmary, March,  1899,  on  account  of  a  tumour  of  the  gall- 
bladder, noticed  a  month,  but  following  on  gall-stone 
symptoms  of  several  years'  duration. 

On  March  28,  cholecystotomy  was  performed,  and  after 
several  ounces  of  straw-coloured  fluid  mixed  with  pus  had 
been  withdrawn  through  an  aspirator  needle,  the  gall-bladder 
was  opened,  and  fourteen  faceted  gall-stones  were  removed 


254    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

from  it  and  the  cystic  duct,  the  largest  being  the  size  of  a 
small  walnut,  the  smallest  the  size  of  a  pea.  Exploration 
within  the  duct  by  means  of  a  long  probe,  and  outside  the 
duct  by  the  finger  in  the  abdomen,  failed  to  discover  any 
further  obstruction.  A  drainage-tube  was  inserted  into  the 
gall-bladder  and  surrounded  by  a  purse-string  suture;  the 
edges  of  the  opening  were  then  fixed  by  sutures  to  the 
aponeurosis.  Bile  appeared  on  the  dressings  on  the  follow- 
ing day,  the  drainage-tube  was  removed  on  the  sixth  and  the 
sutures  on  the  eighth  day.  No  bile  was  discharged  after  the 
ninth,  and  the  wound  was  perfectly  healed  on  the  thirteenth 
day  after  operation.  The  patient  returned  home  on  the 
seventeenth  day.  A  simple  operation  like  that  just  given  is 
quite  the  exception,  the  gall-bladder  being  usually  contracted 
and  surrounded  by  adhesions  ;  moreover,  in  these  cases  the 
obstruction  will  usually  be  found  in  the  cystic  or  common 
ducts.  The  advantage  of  the  complete  operation  that  I  have 
described,  in  which  the  edge  of  the  liver  is  lifted  up  and  the 
bile  passages  brought  well  under  view,  will  be  experienced  in 
this  class  of  cases. 

Management  of  Contracted  Gall-bladder. — The  next  question 
will  be,  How  is  the  contracted  gall-bladder  to  be  dealt  with  ? 
If  it  is  too  small  to  be  brought  to  the  parietes,  but  sufficiently 
large  to  admit  a  drainage-tube,  the  method  of  fixing  the 
tube  by  purse-string  suture  just  described  will  be  quite  safe, 
even  if  the  opening  in  the  gall-bladder  has  to  be  left  2  or  3 
inches  from  the  surface,  for  the  omentum  can  be  made  to  lie 
against  the  tube,  and  by  the  time  that  the  catgut  is  dissolved 
a  track  of  adhesions  will  have  formed  that  will  quite  effectually 
prevent  extravasation  ;  but  in  order  to  make  assurance  doubly 
sure  I  frequently  insert  a  small  split  drainage-tube  with  a 
little  gauze  in  it,  passing  it  quite  down  to  the  gall-bladder, 
and  bringing  it  out  by  the  side  of  the  first  tube. 

Isolation  of  a  Drainage  Track  by  Omentum  and  by  Gauze. — 
Mrs.  N.,  aged  fifty-seven,  seen  with  Dr.  H.  Well  till  eight 
months  ago.  Never  had  spasms  or  jaundice  previously.  Six 
attacks  in  eight  months.  The  pain,  which  is  severe,  begins  at 
the  epigastrium  and  passes  to  the  right  infrascapular  region. 
Examination  negative  but  for  tenderness  over  gall-bladder. 


GALL-STOXES,  OR  CHOLELITHIASIS 


-:>:> 


Operation,  December  15,  1898. — Very  adherent  dilated 
stomach,  with  contracted  gall-bladder,  containing  thick 
mucus  and  gall-stones.  Separation  of  adhesions  and  chole- 
cystotomy  performed,  but  as  the  gall-bladder  could  not  be 
fixed  to  the  parietes  a  tube  was  fixed  in  it  and  isolated  by 
iodoform  gauze.  Good  recovery ;  tube  removed  on  ninth 
day.  Patient  has  been  quite  well  since  recovering  from  the 
operation. 

If  the  gall-bladder  be  so  contracted  as  to  be  incapable  of 
admitting  a  tube,  it  may  either  be  closed  by  suture,  the  line 
of  union  being  protected  from  hurtful  leakage  by  a  strip  of 
gauze  laid  over  it  and  brought  to  the  surface  through  a  rubber 
tube,  or  the  contracted  and  useless  remains  of  the  gall-bladder 
may  be  removed  by  cholecystectomy. 

Before  adopting  the  method  for  complete  exposure  of  the 
whole  biliary  passages,  the  shrivelled  and  useless  gall-bladder 
was  frequently  left  after  clearing  out  its  contents,  with  the 
result  that  relapse  sometimes  occurred  and  cholecystec- 
tomy had  subsequently  to  be  faced,  as  in  the  following  case  : 

Case  229. — Cholecystotomy — Recurrence  of  Symptoms — Chole- 
cystectomy— Recovery. — Mr.  A.,  aged  fifty-six,  seen  with  Dr.  C. 
and  Dr.  A.,  of  Nottingham,  for  loss  of  flesh,  general  ill- 
health,  and  frequently  recurring  pains  in  the  right  hypochon- 
drium,  the  illness  being  of  several  years'  standing. 

Cholecystotomy ,  September  4,  1898. — Contracted  gall-bladder 
with  adhesions  to  the  surrounding  parts,  the  result  of  gall- 
stone irritation  ;  cholecystotomy  performed,  the  gall-bladder 
being  isolated  by  a  gauze  drain.  This  was  followed  by  relief 
for  some  months,  when  the  painful  attacks  recurred,  accom- 
panied by  rigors  and  slight  catarrhal  jaundice. 

Cholecystectomy. — A  further  operation  was  advised,  and 
on  March  3,  1899,  the  shrivelled  gall-bladder,  containing 
muco-pus,  was  removed,  a  small  tube  being  passed  into  and 
fixed  in  the  cystic  duct.  Bile  flowed  freely  the  next  day. 
Ultimately  the  patient  made  a  complete  recovery,  and  when 
seen  in  1902  he  was  in  robust  health,  and  said  he  had  had  no 
further  trouble. 

This  and  other  similar  cases  of  contracted  gall-bladder  led 
me  to  adopt  the  operation  of  cholecystectomy  more  frequently 


256    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

in  certain  cases,  where  to  leave  the  gall-bladder  means  leav- 
ing a  useless  and  diseased  appendage  lined  with  mucous 
membrane,  that  is  certain  to  secrete  mucus,  which  is  apt  to 
be  retained  owing  to  the  cystic  duct  contracting  and  becom- 
ing strictured  as  the  result  of  long-continued  irritation  and 
ulceration.  This  mucus,  retained  under  tension,  becomes 
infected,  and  a  state  of  affairs  much  resembling  chronic 
appendicitis  is  apt  to  continue  until  either  the  gall-bladder 
undergoes  atrophy  and  absorption,  a  condition  which  may  be 
termed  cholecystitis  obliterans  (see  p.  66),  and  which  I  have 
seen  on  several  occasions,  or  the  patient  is  worn  out  by 
repeated  pain  and  chronic  septicaemia,  unless  a  further  opera- 
tion is  undertaken  to  remove  the  offending  organ.  For  a 
description  of  the  operation  of  cholecystectomy,  see  p.  298. 

If,  as  frequently  happens,  gall-stones  are  so  firmly  fixed  in 
the  cystic  duct  that  they  cannot  be  pressed  backward  into 
the  gall-bladder,  it  is  better  not  to  use  force,  but  to  incise  the 
duct  over  the  stone,  and,  after  clearing  the  duct,  to  close  it 
by  a  double  row  of  sutures  to  mucous  membrane  and  serous 
coat  respectively,  as  in  the  following  case : 

Case  259. — Empyema  of  Gall-bladder — Cystodochotomy  and 
Drainage — Recovery. — Mrs.  G.,  aged  forty-seven,  seen  with 
Dr.  L.,  of  Farsley.  Repeated  gall-stone  seizures  for  two  years  ; 
no  jaundice  ;  no  fever  ;  distended  and  tender  gall-bladder. 

Operation,  March  23,  1899 — .Empyema  of  gall-cyst,  with 
many  small  stones  in  gall-bladder ;  one  large  impacted  stone, 
which  could  not  be  dislodged  from  within,  was  removed  from 
the  cystic  duct  by  direct  incision  ;  drainage  of  gall-bladder 
and  gauze  drain  down  to  sutured  incision  in  duct.  Good 
recovery.     Well  in  1901. 

If  the  concretions  are  in  the  common  duct,  either  fixed  or 
floating,  it  is  just  as  easy,  with  the  duct  well  under  the  eye 
and  near  the  surface,  to  incise  it  and  remove  the  stones  as  it 
is  to  open  the  gall-bladder.  All  such  instruments  as  handled 
needles  and  Halsted's  hammer  are  quite  unnecessary,  for  the 
incision  in  the  duct  can  as  readily  be  closed  by  means  of  a 
curved  round  needle  (sewing-needle  pattern)  in  the  fingers  as 
by  any  more  complicated  apparatus.  But  before  closing  the 
duct  it  is  of  the  utmost  importance  to  ascertain  that  there 


GALL-STONES,  OR  CHOLELITHIASIS  257 

are  no  stones  left  either  in  the  ampulla  of  Vater  or  in  the 
hepatic  duct  ;  and  although  the  fingers  manipulating  the 
outside  of  the  ducts  can  give  information  as  to  any  large 
stones,  it  would  be  easy  to  overlook  small  ones  unless  the 
scoop  is  passed  freely  upwards  into  the  hepatic  ducts  and 
downwards  behind  the  duodenum,  or,  if  necessary,  the  open- 
ing in  the  duct  can  be  made  sufficiently  large  to  admit  the 
finger  for  exploration. 

I  usually  pass  a  large  probe  down  into  the  duodenum 
through  the  papilla  to  be  sure  that  the  passage  is  quite  free. 
In  one  case,  not  being  able  to  pass  the  probe  beyond  the 
papilla,  I  opened  the  duodenum,  and  found  a  stricture  of  the 
common  duct  close  to  its  termination,  which  I  divided  after 
freely  laying  the  papilla  open  over  a  director  (Case  436). 
For  details  and  cases  see  Chapter  XL,  on  Choledocho- 
tomy. 

In  quite  a  number  of  cases  after  the  common  duct  has  been 
cleared  I  have  found  stones  in  the  hepatic  ducts,  which  I  have 
removed  by  the  scoop  or  by  direct  incision  of  the  hepatic  duct 
(Cases  492,  508).  If  a  stone  is  impacted  in  the  duodenal  end 
of  the  common  duct  it  may  sometimes  be  more  easily  reached 
through  a  vertical  incision  in  the  second  part  of  the  duo- 
denum, when  the  concretions  can  be  directly  cut  down  on 
through  the  posterior  wall  of  the  duodenum,  or  the  papilla 
can  be  laid  open  over  a  director  ;  it  is  then  easy  to  pass  the 
gall-stone  scoop  up  the  common  duct  in  order  to  be  certain 
that  it  is  free  from  concretions.  All  that  is  now  necessary  is 
to  close  the  anterior  duodenal  wound  by  a  continuous  catgut 
suture  for  the  mucous  membrane  and  a  continuous  silk  or 
celluloid  thread  for  the  serous  margins  (see  p.  295,  Duodeno- 
choledochotomy) . 

The  only  cases  in  which  I  should  now  think  it  desirable 
to  perform  cholecystenterostomy  are  those  in  which  the 
obstruction  is  a  permanent  one — for  instance,  in  cancer  of 
the  head  of  the  pancreas  and  growth  or  stricture  of  the 
common  duct ;  but  my  experience  of  the  operation  in  malig- 
nant disease  has  not  been  such  as  to  lead  me  to  strongly 
advise  it  (see  Chapter  XIII.,  p.  305,  Cholecystenterostomy). 

Malignant  Disease. — Where  gall-stones  are  associated  with 

*7 


258    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

cancer  of  the  gall-bladder,  liver,  or  pylorus,  a  much  more 
extensive  operation  may  have  to  be  done,  as  in  the  cases 
reported  on  pp.  186-192). 

Intervisceral  Fistula. — In  detaching  adhesions  it  may  be 
found  that  there  is  a  fistula  between  the  gall-bladder  and 
stomach,  pylorus  or  bowel,  and  a  careful  search  must  always 
be  made  for  this,  lest  an  opening  into  one  of  the  hollow 
viscera  be  left,  which  would  probably  mean  extravasation 
and  death.  The  following  are  examples  of  intervisceral 
fistula : 

Case  219. — Cholecystotomy  and  Closure  of  Fistula  between 
Gall-Bladder  and  Stomach. — Mrs.  H.,  aged  sixty,  seen  with 
Dr.  C,  of  Doncaster.  Attacks  of  gall-stone  pain  for  fifteen 
months,  lately  very  frequent,  and  followed  by  slight  jaundice  ; 
constant  dyspepsia,  with  frequent  vomiting  and  steady  loss 
of  flesh. 

Operation,  July  7,  1898. — The  stomach  was  found  firmly 
adherent  to  the  gall-bladder,  and  on  separating  the  adhesions 
a  fistula  between  the  gall-bladder  and  stomach  was  found. 
The  edges  of  the  stomach  fistula  were  pared,  and  the  opening 
was  closed  with  two  rows  of  sutures.  Through  the  fistula  in 
the  gall-bladder  the  gall-stones  were  removed  and  drainage 
carried  out.  The  patient  made  an  excellent  recovery,  and  is 
now  in  good  health. 

Case  304. — Closure  of  Fistida  between  Gall-bladder  and  Colon. 
— Mr.  G.,  aged  fifty,  seen  with  Dr.  W.  No  previous  history 
of  spasms.  First  attack  of  gall-stone  colic  in  October,  1897, 
followed  by  jaundice;  several  seizures  in  December,  1897, 
with  jaundice  lasting  two  months  and  associated  with  ague- 
like seizures.  Slight  attacks  for  a  year,  and  then  one  very 
severe  in  December,  1898,  and  again  in  January,  1899. 
During  the  whole  period  the  icterus  deepened  after  each 
attack,  and  occasionally  rigors  occurred  ;  lost  over  2I  stones 
in  weight  ;  jaundiced,  but  not  deeply  ;  liver  not  enlarged  ; 
no  tumour  of  gall-bladder  ;  tenderness  above  and  to  right  of 
umbilicus  ;  well-marked  dilatation  of  stomach. 

Operation,  January  28,  1900. — Fistula  between  shrunken 
gall-bladder  and  colon  discovered ;  cystic  duct  shrunken. 
Cholecystectomy  ;  common    duct    dilated    to   size   of  small 


GALL-STONES,  OR  CHOLELITHIASIS  259 

intestine,  and  containing  large  floating  gall-stone ;  calculus 
crushed,  and  fragments  manipulated  back  through  opening 
left  by  incision  of  cystic  duct  ;  tube  introduced  into  common 
duct;  fistulous  opening  into  colon  closed.  Uninterrupted 
recovery. 

Gall-stones  and  Pyloric  Stenosis. — If  with  the  gall-stones 
pyloric  stenosis  be  found,  then  pyloroplasty  or  gastro- 
enterostomy will  have  to  be  performed,  as  in  the  follow- 
ing cases : — 

Case  385. — Cholccystotomy ,  Choledochotomy,  Pyloroplasty. — 
Miss  T.,  aged  forty-five,  seen  with  Dr.  W.,  of  Harrogate. 
History  of  gall-stone  attacks  with  slight  jaundice  for  several 
years.  History  of  gastric  ulceration  with  stomach  symptoms 
for  two  years  ;  great  loss  of  weight  and  strength  ;  dilatation 
of  stomach  and  tenderness  over  gall-bladder  region,  but  no 
tumour. 

Operation,  August  5,  1901. — Pyloric  stenosis  with  dilatation 
of  stomach  found  together  with  gall-stones  in  gall-bladder  and 
common  duct ;  twenty  gall-stones  removed  from  gall-bladder 
by  cholecystotomy,  and  two  removed  from  common  duct  by 
choledochotomy.  Pylorus  treated  by  pyloroplasty.  Smooth 
and  rapid  recovery.  July,  1902,  patient  very  well,  and  had 
gained  over  2  stones  in  weight. 

Case  488. — Cholecystotomy — Excision  of  Chronic  Gastric  Ulcer 
— Gastroenterostomy — Recovery. — Mr.  S.,  fifty-five  years  of  age, 
who  had  suffered  from  indigestion  for  several  years,  began  to 
have  severe  pain  about  an  hour  after  food,  and  to  lose  flesh 
and  look  ill  during  the  six  months  before  I  saw  him.  A 
doubtful  tumour  could  be  recognised,  and  during  the  attacks 
of  pain  the  stomach  could  be  felt  to  harden  under  the  hand. 
Free  HC1  was  present  after  a  test  meal.  The  serious  nature 
of  his  ailment  was  brought  home  to  the  patient  by  his 
inability  to  continue  his  business,  and  on  the  advice  of  Dr. 
McGregor  Young  I  saw  him,  and  supported  the  opinion  as  to 
exploration.  On  operating,  I  found  the  swelling  to  be  a 
greatly  thickened  pylorus,  forming  a  distinct  tumour,  and 
that  about  ih  inches  from  the  pylorus  along  the  lesser  curva- 
ture was  another  tumour,  wrhich,  from  the  enlargement  of 
the  glands,  we  suspected  might  be  growth  ;  but,  on  opening 

17—2 


260    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

the  stomach,  it  was  found  that  the  pyloric  swelling  was  an 
enormously  hypertrophied  sphincter,  and  that  the  stomach 
tumour  was  thickening  around  a  chronic  ulcer.  The  latter 
was  freely  excised  by  everting  the  portion  of  stomach  in- 
volved and  grasping  it  by  means  of  the  rubber-covered  border 
of  my  gastroenterostomy  clamps,  which  effectually  controlled 
all  bleeding.  An  elliptical  incision  was  then  made,  so  as  to 
include  the  ulcer  in  its  whole  thickness  and  extent ;  after 
excision,  the  sides  of  the  wound  in  the  stomach  where  the 
ulcer  had  been  were  brought  together  by  two  continuous 
sutures,  the  first  embracing  the  muscular  coat  and  the  second 
the  mucous  edges.  When  the  clamps  were  removed  there 
was  no  bleeding  from  the  sutured  wound.  The  stomach 
opening  was  closed,  and  a  posterior  gastroenterostomy  was 
then  performed.  As  the  gall-bladder  was  full  of  thickened 
mucus  and  gall-stones,  it  was  at  the  same  time  emptied  and 
drained.  A  smooth  recovery  has  been  followed  by  restora- 
tion to  health.     Patient  in  good  health  November,  1903. 

Cholelithiasis  and  Enlargement  of  Pancreas. — In  common- 
duct  cholelithiasis,  especially  where  there  is  a  small  floating 
gall-stone,  it  is  common  to  find  the  head  of  the  pancreas 
enlarged  and  hard,  the  result  of  chronic  pancreatitis.  This 
will  give  rise  to  the  suspicion  of  cancer  of  the  head  of  the 
pancreas,  and  may  lead  to  an  unfavourable  prognosis  being 
given  ;  but  the  following  out  of  many  cases  that  I  have  had 
shows  that  it  is  well  to  reserve  our  opinion  in  such  cases,  and 
to  give  the  patient  the  hope  of  cure. 

Case  285. — Enlargement  of  Head  of  Pancreas,  suggesting 
Malignant  Disease  —  Cholecystenterostomy  —  Recovery.  —  On 
October  20,  1899,  a  lady,  aged  fifty-one,  was  seen  with 
Dr.  S.,  of  Sunderland,  who  had  been  suffering  for  three  years 
from  attacks  resembling  those  of  gall-stones,  each  attack 
being  followed  by  jaundice.  During  the  past  fourteen  weeks 
the  seizures  had  been  more  frequent  and  severe,  and  jaundice 
had  never  quite  cleared  away  before  another  attack  came. 
She  had  lost  flesh  and  strength  considerably,  and  had  vomited 
from  time  to  time  between  the  attacks.  Her  digestion  was 
much  impaired,  and  there  was  a  want  of  appetite.  She  had 
had  rigors,  but  recently  had  only  had  slight  fever  at  the  time  of 


GALL-STONES,  OR  CHOLELITHIASIS  261 

each  seizure.  The  urine  contained  abundant  lithates  and  a 
slight  trace  of  albumin,  but  no  sugar.  On  examination,  the 
abdomen  showed  no  manifest  enlargement  of  the  liver  or  gall- 
bladder, but  some  tenderness  over  the  gall-bladder  and  at  the 
epigastrium,  where  there  was  an  indefinite  sense  of  fulness. 

Operation,  October  23. — After  detaching  numerous  adhesions, 
fifteen  gall-stones  were  removed  from  the  cystic  ducts;  but  as 
a  large  nodular  mass  was  occupying  the  head  of  the  pancreas 
and  partly  obstructing  the  common  duct,  it  was  deemed  advis- 
able to  perform  cholecystenterostomy,  so  as  to  make  a  perma- 
nent opening  between  the  fundus  of  the  gall-bladder  and  the 
duodenum.  The  tumour  gave  the  impression  both  to  myself 
and  to  Dr.  S.  that  it  was  malignant.  Recovery  was,  however, 
uninterrupted  ;  the  button  was  passed  on  the  tenth  day  ;  the 
wound  healed  by  first  intention,  and  the  patient  immediately 
began  to  put  on  flesh.  She  returned  home,  and  has  since 
been  perfectly  well  in  every  respect.  It  is  now  over  three  years 
since  the  operation,  and  her  health,  I  am  informed,  is  perfect. 

Cholelithotrity. — I  have  almost  entirely  given  up  cholelitho- 
trity  as  a  set  operation,  as,  although  in  my  earlier  operations  it 
answered  well  in  some  cases,  in  several  the  fragments  did  not 
pass,  and  gave  further  trouble  or  led  to  relapse.  Moreover, 
the  very  complete  exposure  obtained  by  the  operation  I  have 
described  renders  all  uncertain  methods,  such  as  crushing, 
quite  unnecessary. 

The  After-Treatment. 

I  consider  this  almost  as  important  as  the  operation 
itself.  Expedition  in  operating  is  an  important  factor  in 
lessening  shock,  especially  in  abdominal  surgery,  for  it 
stands  to  reason  that  prolonged  manipulation  and  exposure 
of  the  viscera  in  patients  so  ill,  as  the  class  of  cases  we 
are  now  considering  must  generally  be,  will  be  badly 
borne ;  as  it  is  not  only  the  work  of  the  surgeon,  but 
the  deep  anaesthesia  that  adds  to  the  shock,  since  for  these 
operations  to  be  expeditiously  performed  the  muscles  must 
be  well  relaxed.  Choledochotomy  should  occupy  from  half 
an  hour  to  an  hour,  and  only  in  case  of  unusual  complications 
a  little  longer. 


262    DISEASES  OE  THE  GALL-BLADDER  AND  BILE-DUCTS 

After  operation  i  pint  of  saline  fluid  with  i  ounce  of  brandy 
is  given  by  enema,  and  5  minims  of  liq.  strychnia^  are  given 
subcutaneously,  this  being  repeated  if  called  for.  Sub- 
cutaneous injections  of  saline  fluid  or  intravenous  infusion 
are  only  rarely  required. 

Beyond  teaspoonfuls  of  hot  water  or  hot  tea  from  time  to 
time,  all  feeding  is  by  the  rectum  for  the  first  twenty-four 
hours,  though  if  there  is  no  vomiting  the  teaspoonful  of 
water  is  increased  to  a  tablespoonful,  or  even  two,  every 
hour.  After  forty-eight  hours,  if  there  is  no  vomiting,  milk 
and  soda  and  barley-water  can  be  freely  given.  A  little 
plasmon  dissolved  in  the  tea  or  beef-tea  or  barley-water  con- 
siderably adds  to  the  nutritive  value  of  the  fluid.  Light 
custard  pudding  is  usually  given  on  the  fourth  day,  fish  on 
the  fifth,  and  chicken  on  the  sixth,  after  which  the  diet 
becomes  almost  normal. 

The  bowels  are  not  disturbed  before  the  fifth  or  sixth  day, 
and  then  only  by  enema,  unless  there  is  vomiting  or  disten- 
sion, and  in  case  of  either  of  these  complications  1  grain  of 
calomel  is  administered,  and  followed  by  2  ounces  of  apenta 
water  every  two  hours  until  it  acts  or  until  flatus  passes 
freely,  this  being  at  times  helped  by  the  rectal  tube  or  by 
turpentine  enema. 

Morphine  is  avoided  after  all  my  abdominal  operations,  as 
it  tends  to  paralyze  the  intestines  and  leads  to  an  accumula- 
tion of  flatus.  I  believe  that  abstention  from  the  use  of 
morphine  is  a  great  feature  in  the  success  of  abdominal 
surgery,  just  as  I  feel  sure  that  in  the  past  it  has  killed  many 
patients  who  would  otherwise  have  done  well. 

If  a  sedative  is  needed,  10  grains  of  aspirin  will  be  found 
useful,  and  this  can  be  repeated  in  two  hours  if  required.  In 
case  of  vomiting  being  troublesome  or  epigastric  distension 
persisting,  gastric  lavage  will  be  found  useful,  and  when  the 
stomach  is  emptied,  a  dose  of  apenta  water  may  be  left  in  it 
to  incite  peristalsis.  Under  the  circumstances  no  food  or 
fluid  is  allowed  by  the  mouth,  but  plenty  of  fluid  in  the  shape 
of  normal  saline  is  given  by  the  rectum. 

As  a  rule,  recovery  is  uneventful,  and,  for  the  most  part, 
after-treatment  is  negative.     The  stitches  are  removed  on  the 


GALL-STONES,  OR  CHOLELITHIASIS  263 

eighth  day,  and  the  tube  usually  comes  away  about  the  same 
time  ;  the  wound  generally  will  have  healed  by  first  inten- 
tion, and  the  spot  where  the  tube  was  heals  by  granulation. 
The  dressings  are  of  the  simplest,  sterilized  gauze  and 
sterilized  wool  being  employed  as  a  rule,  double  cyanide 
gauze  just  boiled  being  sometimes  used  next  to  the  wound. 

The  chief  lessons  we  have  to  teach  are  that  we  should 
operate  earlier,  before  serious  complications  have  ensued,  and 
that  when  we  do  operate  we  should  be  thorough,  expeditious, 
and  careful. 

Further  Details  concerning  Operations  on  the  Biliary  Passages. 

Having  considered  operations  on  the  gall-bladder  and  bile- 
ducts  as  a  whole,  we  may  now  review  various  points  in  the 
technique  of  the  various  operations  in  detail. 

Position  of  Patient. — It  has  been  proposed  to  suspend  the 
upper  part  of  the  trunk  when  the  patient  is  on  the  operating- 
table  by  straps  placed  under  the  arm-pits,  in  order  to  allow 
the  intestines  to  fall  away  from  the  liver,  and  thus  to  afford 
a  better  view  of  the  parts  to  be  operated  on,  just  as  the 
Trendelenburg  position  does  in  the  case  of  the  pelvic  organs  ; 
but  this  is  both  inconvenient  and  impracticable,  and  the 
same,  or  even  a  better  effect  can  be  obtained  by  the  employ- 
ment of  a  narrow,  firm  sand-bag,  as  described  on  p.  249. 

The  Incision. — I  now  always  make  my  incision  over  the 
middle  of  the  right  rectus  in  a  line  parallel  with  its  fibres,  as 
described  on  p.  249,  and  illustrated  on  p.  264. 

Kocher  employs  an  oblique  incision  parallel  to  the  right 
costal  margin,  which  of  necessity  divides  muscles  and  nerves, 
but  which  exposes  the  parts  freely,  as  the  wound  at  once 
gapes  widely. 

•  Mr.  Rutherford  Morison  also  advocates  the  oblique  incision, 
which  he  extends  very  freely  when  the  common  duct  has  to 
be  exposed.  Our  objections  to  the  oblique  incision  are  the 
necessarily  extensive  division  of  muscles,  vessels,  and  nerves, 
and  the  difficulty  of  securing  exact  apposition  subsequently, 
thus  leaving  a  weak  scar,  with  a  tendency  to  ventral  hernia. 

The  lumbar  incision,  which  has  been  suggested  in  order 
to  reach  the  common  duct  without  opening  the  peritoneum, 


264    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

is  useful  only  in  theory,  and  is  surrounded  by  so  many 
difficulties  as  to  make  it  quite  impracticable  as  an  ordinary 
procedure. 

Arrest  of  Haemorrhage. — As  a  rule,  pressure  forceps  and  an 
occasional  ligature  effect  all  that  is  desirable  or  necessary  ; 
but  in  cases  of  long-standing  jaundice,  especially  if  accom- 
panied by  malignant  disease,  additional  precautions  are 
advisable  on  account  of  the  tendency  to  haemorrhage.  Cases 
II»  354)  5J6,  in  the  appendix  are  good  examples. 


Line  showing  ordinary 
incision  and  exten- 
sion for  more  complete 
exposure. 


Fig.  65. — Diagram  to  show  Incision. 


The  following  cases,  taken  from  a  paper  by  Dr.  Osier 
(American  Medicine,  April  27,  1902),  and  coming  under  his 
care  within  a  few  months,  show  how  serious  the  hemorrhagic 
condition  is : 

*  1.  A  woman,  admitted  on  January  9  ;  jaundice  of  four 
months'  duration  ;  recurring  attacks  of  pain  ;  blood  coagula- 
tion time,  ten  minutes.     The  condition  was  very  serious,  and 


GALL-STONES,  OR  CHOLELITHIASIS  265 

the  pain  was  so  severe  that  an  exploratory  operation  was  per- 
formed on  January  29.  Carcinoma  of  the  gall-bladder  and 
of  the  liver  was  found.  She  bled  profusely  during  the  night 
following  the  operation,  and  continued  to  bleed  until  death 
(on  February  1). 

1  2.  A  woman,  admitted  January  30;  jaundice  of  four  months' 
duration,  with  recurring  intermittent  fever,  associated  with 
stones  in  the  common  duct ;  blood  coagulation  time  on  ad- 
mission, eight  minutes,  gradually  reduced  by  the  use  of 
calcium  chloride  to  three  and  a  quarter  minutes. 

1  Operation,  March  5. — Numerous  gall-stones  in  gall-bladder 
and  in  common  duct.  Haemorrhage  the  day  after  operation, 
with  the  formation  of  hematoma,  March  9  ;  very  severe 
bleeding  with  collapse  ;  gradual  recovery. 

'  3.  A  woman,  admitted  on  February  19,  with  a  remarkable 
jaundice  of  nearly  ten  years'  duration.  She  had  had  recur- 
ring attacks  of  haemorrhage,  chiefly  from  the  nose  and  from 
the  uterus,  in  two  of  which  she  nearly  died.  She  was 
admitted,  pulseless  and  blanched,  in  the  third  attack.  The 
haemoglobin  was  20  per  cent.,  the  red  blood  corpuscles  were 
1,600,000.  Both  she  and  the  previous  patient  had  multiple 
xanthoma.  Coagulation  time  on  admission,  fourteen  minutes  ; 
a  month  later  it  was  four  and  half  minutes,  and  her  blood 
corpuscles  had  risen  to  4,000,000  per  cubic  millimetre.  On 
March  22,  she  had  a  little  epistaxis  and  a  few  spots  of  haemor- 
rhage in  the  skin.  Considering  the  remarkable  tendency  to 
haemorrhage  even  when  her  coagulation  time  was  at  four 
minutes,  that  her  general  condition  was  good,  and  that  she 
seemed  to  be  accustomed  in  an  extraordinary  way  to  the 
persistent  jaundice,  operation  was  not  advised. 

1 4.  A  stout,  healthy-looking  woman  was  admitted  on 
February  19,  with  pain,  nausea,  vomiting,  and  jaundice  of  four 
weeks'  duration.  She  had  a  good  deal  of  vomiting  while  in 
the  ward.  The  blood  coagulation  time  was  three  and  a  half 
minutes.  The  nature  of  the  case  was  doubtful,  and  she  was 
transferred  to  the  surgical  side.  The  day  before  operation 
she  became  collapsed,  had  haematemesis,  and  died.  The 
necropsy  showed  gall-stones,  cancer  of  the  neck  of  the  gall- 
bladder, extensive  haemorrhage  into  the  lesser  peritoneum  and 


266    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

about   the  tail  of  the  pancreas,   and  haemorrhage   into  the 
stomach. 

'  5.  A  man  was  admitted  who  had  been  under  care  a  year 
before  with  jaundice  of  four  years'  duration.  An  operation 
was  performed.  On  attempting  to  separate  the  adhesions 
about  the  ducts  he  bled  so  profusely  that  the  operation  had  to 
be  abandoned.' 

Should  there  be  chronic  jaundice  or  a  tendency  to  haemor- 
rhage, calcium  chloride  is  given ;  for  although  there  is  a 
greater  tendency  to  bleeding  in  chronic  jaundice  from  pan- 
creatic disease  than  when  jaundice  is  due  to  gall-stone  ob- 
struction, I  think  there  can  be  no  doubt  that  in  all  cholaemic 
conditions  the  blood  becomes  so  altered  that  the  coagulability 
becomes  seriously  diminished ;  hence,  these  factors  demand 
serious  attention  before  any  operation  is  undertaken  in  cases 
of  common-duct  cholelithiasis. 

After  reading  Professor  Wright's  researches  on  the  coagula- 
bility of  the  blood  (British  Medical  Journal,  December  18, 
1891),  my  mind  was  prepared  to  grasp  the  possibility  of  turn- 
ing the  experience  gained  on  dogs  to  practical  uses  in  the 
human  subject,  as  I  had  lost  two  jaundiced  patients,  one  in 
1888  and  one  in  1890,  from  persistent  oozing  of  blood  subse- 
quent to  operation.  I  therefore  at  once  began  to  employ  it 
in  these  cases,  and  with  benefit ;  but  it  has  been  only  within 
the  last  three  years  that  I  have  been  able  to  get  at  the  real 
value  of  the  drug,  which  is  one  I  now  always  employ  in 
jaundiced  patients,  both  before  operation  in  30-grain  doses  by 
the  mouth  for  two  or  three  days,  and  afterwards  in  60-grain 
doses  by  the  rectum  thrice  daily  for  two  or  three  days,  or 
longer  if  needful. 

As  bearing  out  these  observations,  the  following  extract 
from  the  Paris  correspondent  of  the  Medical  Press,  Novem- 
ber 23,  1902,  is  worth  noting : 

'  The  great  haemostatic  value  of  chloride  of  calcium  adminis- 
tered internal]}-  has  not  yet  been  entirely  accepted,  and  yet 
it  can  in  nearly  all  cases  be  depended  upon.  Dr.  Bertignon 
took  recently  as  the  subject  of  his  thesis  this  drug,  and  fur- 
nished a  series  of  cases  in  which  chloride  of  calcium  was 
proved  to  be  an  excellent  haemostatic.     He  remarked  that — 


GALL-STONES,  OR  CHOLELITHIASIS  267 

'  It  succeeded  where  perchloride  of  iron,  antipyrin,  ergotin, 
and  hot  injections  failed,  and  was  indicated  in  hemorrhages  of 
every  kind,  and  in  all  maladies  presenting  hemorrhagic  com- 
plications. He  stated  that  hematemesis,  hematuria,  enteror- 
rhagia,  and  metrorrhagia  are  arrested  rapidly  by  CaCL/ 
M.  Bertignon  cited  the  case  of  a  patient  suffering  from 
acute  general  purpura  benefited,  where  ergotin,  perchloride 
of  iron,  citric  acid,  etc,  were  tried  without  success. 

Germain  See,  speaking  on  the  subject,  said  that  of  all  the 
coagulating  solutions  known,  chloride  of  calcium  was  the 
most  easily  borne  by  the  stomach.  In  more  than  one  in- 
stance at  the  hospital  had  he  seen  it  succeed  when  prescribed 
for  grave  hematemesis. 

In  jaundiced  cases  it  is  always  desirable  to  ligature  all 
bleeding-points  rather  than  to  trust  to  pressure  forceps  for 
hemostasis.  The  subcutaneous  injection  of  gelatin  has 
been  tried  rather  extensively  abroad,  but  from  the  little  I  have 
seen  of  its  use  in  England  I  decidedly  prefer  the  calcium 
chloride. 

A  2  per  cent,  solution  of  gelatin  in  normal  saline  fluid, 
and  sterilized  before  use,  is  injected  into  the  subcutaneous 
tissues  in  quantities  of  from  4  to  6  ounces  ;  it  causes  con- 
siderable pain  for  a  little  time,  and  generally  a  rise  of  tem- 
perature to  ioo°  F.  or  more. 

In  chronic  jaundice  cases  it  may  be  injected  a  day  or  two 
before  operation,  on  the  day  of  operation,  and  subsequently, 
according  to  circumstances.  It  must  not  be  forgotten  that 
some  cases  of  tetanus  have  occurred  after  the  subcutaneous 
injection  of  gelatin.  Perhaps  the  administration  of  gelatin 
by  the  mouth  or  by  the  rectum  in  the  shape  of  jelly  or 
broth  may  be  found  useful. 

As  a  general  styptic,  suprarenal  extract  is  sometimes  most 
useful,  and  Dr.  Soltau  Fenwick,  in  a  communication  to  the 
British  Medical  Journal,  November  30,  1901,  says  that  he  has 
abandoned  all  other  methods  of  treatment  in  bleeding  from 
the  stomach  in  its  favour.  The  plan  usually  adopted  was  to 
administer  10  rluid  ounces  of  freshly-prepared  concoction 
containing  2  grains  of  the  desiccated  gland  to  the  ounce  as 
soon    as    possible  after  an  attack   of  haematemesis,   and   to 


268    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

repeat  the  dose  at  the  end  of  two  hours.  In  two  instances 
where  melena  was  the  sole  symptom,  three  doses  were  given 
in  four  hours.  In  no  case  were  unpleasant  symptoms  ob- 
served, though  occasionally  the  first  dose  produced  an  indica- 
tion of  vomiting.  This  method  of  treatment  might  prove  of 
great  service  in  gall-bladder  surgery,  in  case  of  that  serious 
complication  of  post-operative  haematemesis,  which  is  appar- 
ently dependent  on  capillary  haemorrhage  from  the  congested 
mucous  membrane,  and  which  was  the  cause  of  death  in  one 
of  the  cases  reported  in  the  appendix. 

Suture  of  Abdominal  Wound.  —  In  order  to  remove  the 
danger  of  ventral  hernia,  the  abdominal  wround  should  be 
sutured  layer  by  layer,  employing  buried  catgut  for  the  deep 
and  silkworm  gut  for  the  superficial  sutures  ;  but  if  the 
operation  has  been  very  prolonged,  and  the  patient  be 
suffering  from  shock,  it  may  be  advisable  to  suture  the 
parietes  en  masse,  using  silk  of  medium  thickness  or  Pagen- 
stecker's  thread,  and  passing  the  sutures  through  all  the 
layers  from  within  outward  at  intervals  of  J  inch.  Where  it 
is  considered  necessary  to  employ  gauze-packing  or  a  wick 
drain,  it  is  well  to  apply  the  sutures  and  to  leave  them  long, 
so  as  to  be  able  to  draw  the  edges  of  the  wound  together 
after  the  tampon  has  been  removed  without  putting  the 
patient  to  the  inconvenience  of  inserting  stitches  later. 

Drainage. — In  an  ordinary  gall-stone  operation,  drainage  of 
the  abdomen,  apart  from  drainage  of  the  gall-bladder,  is 
usually  unnecessary  ;  but  where  the  ducts  have  had  to  be 
incised,  as  in  choledochotomy,  and  any  infected  bile  has 
escaped  and  soiled  the  tissues,  drainage  is  safer,  for,  owing 
to  the  separation  of  adhesions,  there  is  generally  some  pour- 
ing out  of  fluid  immediately  after  operation,  and  should  this 
become  infected  a  fear  of  septic  complications  is  far  from 
problematical. 

A  stab  wound  in  the  loin,  through  which  a  tube  is  passed 
into  the  right  kidney  pouch,  effectually  prevents  any  accumu- 
lation, but  an  even  simpler,  and  in  my  experience  an  equally 
efficient,  method,  is  to  split  an  ordinary  medium-sized  rubber 
tube,  and  in  it  to  insert  a  piece  of  aseptic  gauze,  just  project- 


GALL-STONES,  OR  CHOLELITHIASIS  269 

ing  from  the  end  of  the  tube.  This  is  passed  down  to  the 
region  of  the  duct  that  has  been  sutured,  and  brought  out  by 
the  side  of  the  tube  that  is  draining  the  gall-bladder.  In 
twenty-four  hours  this  tube  may  be  replaced  by  a  smaller  one 
prepared  beforehand,  and  in  another  twenty-four  hours  that 
may  be  removed  and  not  replaced. 


CHAPTER  VIII 

CHOLECYSTOTOMY 

Cholecystotomy,  or  cholecystostomy,   usually   follows   on 
exploration,  as  it   is   unquestionably  the  operation  par  excel- 
lence in  the  treatment  of  gall-stones. 
The  indications  for  the  operation  are  : 

1.  In  cases  where  the  gall-bladder  is  sufficiently  large  to 
permit  of  drainage,  after  gall-stones  have  been  removed  from 
the  gall-bladder  or  ducts. 

2.  Very  rarely  in  cases  where,  although  there  are  gall- 
stones in  the  ducts,  the  patient  is  too  ill  to  bear  a  prolonged 
operation,  the  gall-stones  being  deliberately  left  for  subsequent 
treatment  when  the  patient  is  in  better  condition. 

3.  In  empyema  of  the  gall-bladder,  where  that  viscus  is  not 
too  much  disorganized  to  be  permitted  to  remain. 

4.  In  certain  cases  of  chronic  catarrh  of  the  gall-bladder 
or  bile-ducts. 

5.  In  infective  and  suppurative  cholangitis. 

6.  In  obstruction  of  the  ducts  due  to  hydatid  disease. 

7.  In  dropsy  of  the  gall-bladder  after  removal  of  obstruction. 

8.  In  idiopathic  rupture,  or  laceration,  or  gunshot  injury 
of  the  gall-bladder  or  ducts,  when  cholecystectomy  is  un- 
desirable. 

9.  In  cases  of  choledochotomy,  in  order  to  avoid  tension 
in  the  sutured  duct. 

10.  In  certain  cases  of  obstructive  jaundice  dependent  on 
malignant  tumour,  which  is  occluding  the  ducts.  In  these 
cases  the  increased  danger  must  be  borne  in  mind. 

11.  In  some  cases  of  phlegmonous  cholecystitis  where  the 
patient  is  too  ill  to  bear  cholecystectomy, 

[  270  ] 


CHOLECYSTOTOMY  271 

12.  In  chronic  pancreatitis,  where  at  the  same  time  both 
the  bile  and  pancreatic  ducts  are  drained. 

The  operation  has  been  fully  described  on  p.  249,  but  there 
are  other  points  which  can  be  conveniently  mentioned  here. 

The  description  already  given  applies  to  the  ordinary 
operation  on  a  gall-bladder  of  normal  size,  or  to  one  dis- 
tended, as  well  as  to  a  contracted  gall-bladder  situated  deeply, 
which  can  be  most  easily  dealt  with  when  the  edge  of  the 
liver  can  be  lifted  up  or  the  whole  liver  rotated  ;  but  occasion- 
ally the  liver  is  retracted  beneath  the  costal  margin  or  con- 
tracted in  size,  so  that  the  gall-bladder  has  to  be  dealt  with  at 
some  distance  from  the  surface,  when  the  operation  may  be 
prolonged  and  difficult. 

When  unable  to  bring  up  the  gall-bladder,  it  has  at  times 
been  possible  to  tuck  down  the  parietal  peritoneum  to  the 
edges  of  the  gall-bladder  opening,  and  so  to  effect  suture  of 
the  contiguous  margins  ;  but  in  several  cases  where  this  could 
not  be  done,  the  right  border  of  the  omentum  has  been 
sutured  to  the  margin  of  the  gall-bladder  and  to  the  parietal 
peritoneum,  thus  forming  a  tube  of  peritoneum  around  the 
drainage-tube,  and  shutting  out  the  general  peritoneal  cavity. 
This  method,  which  we  described  some  years  ago,  has  also 
since  been  efficiently  employed  by  others.  Where  occlusion 
in  this  way  cannot  be  effected,  the  insertion  of  a  drainage- 
tube  into  the  gall-bladder,  without  suture  of  the  margins  to 
the  parietes,  seems  to  be  efficient,  for  it  is,  on  account  of 
intra-abdominal  tension,  easier  for  the  bile  to  pass  away 
directly  through  the  tube  than  to  enter  the  abdomen,  and  it 
is  probable  that  within  from  twenty-four  to  forty-eight  hours 
plastic  effusion  shuts  out  the  drainage  track  from  the  general 
peritoneal  cavity. 

Where  the  gall-bladder  is  small  and  deeply  placed,  the  tube 
may  be  inserted  in  it  and  a  running  catgut  suture  applied 
around  the  margin  of  the  incision  in  the  gall-bladder,  so  that 
when  tightened  it  draws  the  edges  of  the  incision  closely 
around  the  tube  ;  the  same  suture  may  then  be  passed  through 
the  tube  and  tied  so  as  to  fix  it  in  position  and  prevent  it 
slipping,  until  the  catgut  softens  in  about  a  week  or  ten  days, 
when  the  tube  can  be  safely  removed.     The  method  of  gauze 


272    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

packing  is  also  a  safe  means  of  shutting  off  the  peritoneal 
cavity. 

In  all  cases  of  drainage  of  the  gall-bladder  I  now  fix  the 
tube  in  by  a  running  catgut  suture  as  just  described,  as  it 
not  only  saves  the  wound  from  contamination,  but  also  saves 
soiling  of  the  dressings,  as  the  discharge  is  conveyed  direct 
into  a  bottle  placed  by  the  side  of  the  patient. 

Mr.  Knowsley  Thornton  suggested  suprapubic  drainage  in 
cases  where  occlusion  of  the  bile  channels  is  doubtful ;  but  if 
drainage  of  the  abdominal  cavity  is  required  in  such  cases, 
it  can  be  done  better  either  by  means  of  a  tube  passed  into 
the  right  kidney  pouch  and  brought  out  at  the  lower  end  of 
the  original  incision,  or  through  a  stab  puncture  in  the  right 
loin,  as  already  described  on  p.  268. 

Dr.  Murphy  has  invented  a  '  button-tube '  for  use  in  cases 
where  the  gall-bladder  is  contracted  and  cannot  be  brought 
to  the  surface ;  but  in  practice  it  will  usually  be  found  that 
the  contracted  gall-bladder  is  too  small  to  permit  of  its  em- 
ployment. In  certain  cases  where  the  gall-bladder  is  con- 
tracted, after  opening  and  clearing  it  and  the  ducts,  the 
incision  may  be  immediately  closed  by  suture,  the  line  of  in- 
cision being  isolated  by  a  gauze  drain ;  or  in  other  cases 
cholecystectomy  may  be  performed  and  the  cystic  duct  liga- 
tured, the  gauze  drain  being  again  employed  ;  or,  as  suggested 
by  Morison,  the  incision  in  the  gall-bladder  may  be  deliberately 
left  patent,  and  the  bile  allowed  to  run  into  the  right  kidney 
pouch,  from  which  it  is  removed  by  a  drainage-tube  in  the 
loin. 

The  operation  of  cholecystotomy  has  been  modified  in 
several  ways ;  for  instance,  the  opening  has  been  closed  and 
then  fixed  to  the  abdominal  incision,  which  has  been  closed 
over  it  ;  this  operation  is  known  as  cholecystendysis 
(Courvoisier). 

It  can  only  be  of  use  where  the  ducts  are  known  to  be 
thoroughly  cleared,  where  there  is  no  fear  of  subsequent  stric- 
ture, and  where  there  is  no  catarrh  or  inflammation  of  the 
bladder  or  bile  passages.  In  Case  116  it  was  employed  for 
the  cure  of  a  biliary  fistula. 

The  so-called  '  ideal '  operation  suggested  by  Langenbach 


CHOLECYSTOTOMY  273 

(Centralb.  fur  Chirurgie,  1887),  in  which  the  opening  in  the 
gall-bladder  is  sutured  and  the  viscus  returned  without  fixing 
it  to  the  surface,  has  been  thought  by  Lange,  Meredith, 
Kuster,  Keen,  and  others,  to  be  attended  with  greater  risk 
than  the  operation  of  cholecystostomy.  If  it  be  thought 
advisable  to  adopt  this  method,  it  is  necessary  to  prove  that 
the  ducts  are  clear,  and  this  may  be  accomplished  by  distend- 
ing the  gall-bladder  with  warm  sterilized  water,  and  then 
forcing  it  through  the  ducts,  or  by  catheterism  of  the  ducts, 
as  advocated  by  Drs.  Terrier  and  Dalby  {Revue  de  Chirurgie). 
Of  these  methods,  the  former  is  to  be  preferred,  both  on 
account  of  its  safety  and  efficiency. 

Recently  reported  cases  of  '  ideal '  cholecystotomy  would 
seem  to  prove  that  the  dangers  at  first  attending  the  opera- 
tion may  be  overcome  by  a  proper  selection  of  cases,  and  by 
carefully  suturing  the  mucous  and  muscular,  and  then  the 
serous,  margins  separately ;  but  the  serious  objection  to  it  is 
that  the  benefits  of  drainage  are  not  obtained,  as  in  the 
ordinary  operation  of  cholecystotomy. 

A  use  for  this  modification  is  found  in  cases  where  it 
has  been  necessary  to  open  a  contracted  gall-bladder,  but 
where,  on  account  of  the  depth,  it  is  found  impracticable  to 
bring  it  to  the  surface ;  also  when,  from  the  contraction  of  its 
cavity,  it  is  found  impossible  to  insert  a  drainage-tube,  but 
in  such  cases  cholecystectomy  is  the  better  operation. 

The  line  of  suture  is  made  secure  against  dangerous  leak- 
age by  the  gauze  drain,  the  lower  end  of  which  is  packed 
moderately  firmly  over  the  gall-bladder. 

Another  modification  suggested  by  Bloch  is  that  in  two 
stages.  The  operation  consists  in  incising  the  parietes  until 
the  peritoneum  is  reached,  the  cavity  of  which,  however,  is 
not  opened  ;  the  wound  is  then  packed  with  gauze  and  left 
for  several  days,  when  adhesions  will  have  formed  between 
the  gall-bladder  and  the  parietal  peritoneum.  The  gall- 
bladder can  then  be  safely  opened.  Or,  if  the  peritoneum 
be  incised,  the  gall-bladder  is  fixed,  but  not  opened  until 
adhesions  have  formed. 

As  the  method  is  only  available  for  the  simplest  cases — viz., 
where  the  gall-bladder  is  distended, — as  it  does  away  with  all 

18 


274    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

chance  of  exploring  the  ducts  by  the  hand  within  the  abdo- 
men, and  as  it  is  frequently  followed  by  fistula,  it  needs 
only  to  be  mentioned  to  be  condemned  as  clumsy  and 
uncertain,  and  no  safer  than  the  ordinary  operation  of  chole- 
cystotomy. 

To  this  opinion  there  may  be  one  exception  :  the  opera- 
tion a  deux  temps  presents  considerable  advantages  when 
cholecystotomy  is  being  undertaken  in  the  presence  of 
chronic  jaundice  associated  with  distended  gall-bladder  in  a 
patient  extremely  ill,  as  in  such  cases  there  is  usually  malig- 
nant disease  either  of  the  head  of  the  pancreas  or  of  the  bile- 
ducts  ;  and  when  the  peritoneum  is  exposed,  but  not  opened, 
pressure  can  be  applied  to  arrest  the  subsequent  oozing  of 
blood,  which  cannot  always  be  prevented  by  ligatures  or 
forceps.  Bloch,  however,  in  his  original  papers,  and  again 
in  the  Revue  de  Chirurgie  for  1895,  does  not  recommend  the 
operation  for  this  reason,  but  on  account  of  the  fear  of  septic 
contamination  of  the  peritoneum,  which  ample  experience 
proves  to  be  groundless. 

Delageniere  {British  Medical  Journal  Supplement,  May  6, 
1889)  exposes  the  gall-bladder  and  raises  the  edge  of  the 
liver  as  high  as  possible  with  a  retractor.  Then  the  peri- 
toneum is  guarded  with  a  compressor  or  sponge,  and  the 
fundus  of  the  gall-bladder  opened.  The  incision  is  enlarged 
with  scissors  along  the  left  aspect  of  the  gall-bladder  till  the 
calculi  to  be  removed  are  reached.  A  Kocher's  forceps  is 
placed  on  each  side  of  the  incision  ;  the  two  will  draw  the 
deeper  parts  well  towards  the  abdominal  wall.  The  duct 
may  be  cut  open  almost  to  its  termination  in  a  bad  case. 
When  the  calculi  are  extracted,  he  closes  the  long  incision  in 
the  duct  and  gall-bladder  with  a  continuous  silk  suture,  and 
applies  an  external  layer  of  interrupted  sutures.  To  establish 
a  biliary  fistula,  about  half  an  inch  of  the  incision  at  the 
fundus  is  left  open.  The  peritoneum  is  then  sutured  all 
round  this  opening  in  the  usual  manner.  A  hole  is  then 
made  in  the  right  rectus  muscle,  and  the  free  piece  of  the 
wall  of  the  gall-bladder  drawn  into  it,  the  edges  of  the  open- 
ing being  stitched  to  the  edges  of  the  hole  in  the  muscle. 
Another  buttonhole  is  made  in  the  skin  over  the  hole  in  the 


CIIOLECYSTOTOMY  275 

rectus,  and  through  this  a  drainage-tube  is  passed  into 
the  gall-bladder.  The  original  abdominal  incision  is  then 
closed. 

The  statistics  of  cholecystotomy  vary  very  considerably 
according  to  the  conditions  for  which  the  operation  is 
performed. 

In  my  own  experience,  where  the  operation  has  been 
undertaken  for  simple  disease,  such  as  gall-stones,  in  the 
absence  of  malignant  disease  and  jaundice  with  suppurative 
and  infective  cholangitis,  there  were  3  deaths  in  281  cases, 
giving  a  mortality  of  i'o6  per  cent. 

If  the  complicated  cases,  such  as  phlegmonous  cholecyst- 
itis, gangrene  of  the  gall-bladder,  suppurative  or  infective 
cholangitis  (all  of  which  are  classified  by  Kehr  as  complicated 
cases)  be  included,  many  of  these  being  not  associated  with 
gall-stones,  the  mortality  is  27  per  cent. 

If  the  malignant  cases,  where  cholecystotomy  has  been 
performed  in  the  presence  of  cancer  of  the  pancreas  or  bile- 
ducts  (22  in  number),  be  included,  the  mortality  of  the  whole 
series  is  5*8  per  cent. 

The  deaths  which  occurred  in  'simple'  cases  were  those  of 
an  old  gentleman,  aged  sixty-six,  who  had  mitral  disease, 
with  evidence  for  some  months  of  failure  of  compensation, 
and  in  whom  operation  was  only  performed  at  his  urgent 
request,  since  his  sufferings  were  such  as  to  induce  him  to 
undertake  the  special  risk ;  of  an  old  man  of  sixty-two,  who 
had  apparently  made  a  good  recovery  from  operation,  but 
died  from  collapse  on  the  twenty-third  day ;  and  of  an 
extremely  stout  middle-aged  woman,  a  morphino- maniac 
who  died  of  pneumonia  on  the  seventh  day. 

Dr.  W.  J.  Mayo,  of  Rochester,  Minnesota,  in  a  paper 
published  in  June,  1902,  in  the  Annals  of  Surgery,  gives  227 
cases  of  cholecystotomy  for  various  simple  conditions,  for  the 
most  part  gall-stones,  with  6  deaths,  or  2'6  per  cent,  mor- 
tality, whereas  in  malignant  disease,  of  4  cholecystotomies 
2  died.  In  a  paper  published  in  the  Boston  Medical  and 
Surgical  Journal,  May  21,  1903,  he  gives  352  cholecystotomies 
for  simple  conditions,  with  8  deaths,  or  a  mortality  of  2*27 
per  cent. ;  whereas  of  5  cases  in  which  cholecystotomy  had 

18—2 


276    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

been  done  for  malignant  disease,  three  died,  equal  to  60 
per  cent,  mortality. 

Courvoisier  gives  the  statistics,  up  to  1890,  of  104  cases, 
the  mortality  being  21*14  per  cent.,  and  16  per  cent,  had 
fistulae.  Of  31  cases  operated  on  in  two  stages,  the  mortality 
was  only  12*5  per  cent.,  but  34  per  cent,  were  left  with  a 
fistula. 

Martig,  up  to  1893,  gave  the  mortality  as  17  per  cent.,  with 
a  fistula  remaining  in  20  per  cent. ;  for  the  operation  a  deux 
temps,  he  gave  a  mortality  of  10  per  cent. 

Kehr,  Halberstadt  {Berlin  Klin.  Woch.,  June  15,  1896), 
gives  the  result  of  209  operations  on  the  gall-bladder  and 
bile-ducts  in  174  patients.  Of  his  simple  cholecystotomies 
there  was  barely  1  per  cent,  of  deaths,  but  of  his  complicated 
cases  the  mortality  was  58'8  per  cent.,  or  a  loss  of  10 
out  of  17  cases,  making  the  all-round  mortality  a  little 
over  6  per  cent.  In  a  later  series  (Langenbeck's  Archives, 
vol.  lviii.,  p.  3)  he  reports  202  operations,  with  a  mortality 
of  32  (16  per  cent.),  and  attributes  the  higher  mortality 
to  the  increased  gravity  of  the  cases.  In  conservative  opera- 
tions on  the  gall-bladder  he  lost  3  patients  out  of  68  opera- 
tions— i.e.,  a  mortality  of  4*4  per  cent. 

In  Kehr's  latest  published  statistics  (Miinchener  Med.  Woch., 
1902)  he  gives  720  laparotomies  for  gall-stones,  with  15*5  per 
cent,  mortality;  the  simple  cholecystotomies  had  2*1  per 
cent,  mortality ;  but  the  complicated  cases,  including  malig- 
nant disease,  had  a  mortality  of  97  per  cent. 

The  late  Greig  Smith  reported  11  simple  cases  without 
a  death,  and  1  complicated  case  which  died,  equivalent  to 
8*33  Per  cent. 

The  late  Lawson  Tait  published  55  cases  with  3  deaths, 
showing  a  mortality  of  5*4  per  cent. 

With  regard  to  recurrence,  if  the  ducts  be  cleared  and  the 
gall-bladder  drained,  relapse  is  rare,  and  I  have  yet  to  see 
my  first  case  in  which  a  genuine  recurrence  of  gall-stones  has 
occurred.     Kehr  and  Mayo  have  had  a  similar  experience. 

An  eminent  operator  recently  said  that  he  found  fistula 
frequently  followed  on  cholecystotomy,  which,  however,  is 
quite    at   variance  with    my  experience  since  adopting   the 


CHOLECYSTOTOMY  277 

modification  of  suturing  the  edge  of  the  gall-bladder  incision 
to  the  aponeurosis  and  not  to  the  skin,  which  distinctly 
proves  that  fistula  will  only  follow  under  such  circumstances 
if  the  ducts  have  not  been  cleared,  and  then  it  is  better  that 
there  should  be  such  a  safety-valve,  which  can  be  remedied 
by  a  further  operation. 

Out  of  the  simple  cholecystotomies  recorded  in  the 
tables  below,  fistula  occurred  in  16  cases.  In  the  first  10 
there  were  5  fistulae  :  these  were  all  operated  on  by  stitching 
the  gall  -  bladder  to  the  skin,  as  proposed  by  Lawson 
Tait.  In  the  later  cases,  where  the  opening  in  the  gall- 
bladder was  sutured  to  the  aponeurosis,  and  not  to  the 
skin,  there  were  only  11  fistulas,  which  were  nearly  all  treated 
by  further  clearing  the  duct  or  short-circuiting  the  obstruc- 
tion. The  more  thorough  operation  which  extension  of  the 
incision  upward  enables  one  to  do,  insures  a  clearance  of  the 
gall-stones  from  the  bile-ducts,  including  the  common  and 
hepatic  ducts ;  there  should,  therefore,  now  seldom  be  need 
for  a  second  operation. 

As  one  would  expect,  cholecystotomy  a  deux  temps  is 
often  followed  by  fistula.  Martig  gives  20  per  cent.,  and 
Courvoisier  34  per  cent.,  which,  of  course,  are  due  to  imper- 
fect clearing  of  the  ducts. 

After  cholecystotomy  has  been  performed  and  the  gall- 
bladder cleared  of  its  contents,  it  may  be  found  impracticable 
to  remove  other  gall-stones  impacted  in  the  cystic  or  common 
ducts,  either  by  means  of  forceps  or  scoop  introduced  through 
the  gall-bladder  incision  or  by  digital  manipulation  from 
without.  Under  such  circumstances  the  gall-stones  must  be 
removed  by  choledochotomy. 


CHAPTER  IX 
CALCULI  IN  THE  COMMON  BILE-DUCT 

According  to  Courvoisier,  this  condition  occurs  in  about 
4  per  cent,  of  all  cases  of  cholelithiasis.  A  reference  to  the 
cases  that  have  come  under  my  care  shows  this  to  be  an 
underestimate,  as,  out  of  380  cases  of  cholelithiasis  operated 
on,  there  were  gall-stones  in  the  common  bile-duct  on  150 
occasions,  which  equals  39*4  per  cent. 

Fenger,  in  the  Annals  of  Surgery,  quoted  Conrade,  who 
said  that  in  97  cases,  he  found  gall-stones  in  the  gall-bladder 
alone  in  82,  in  the  gall-bladder  and  common  duct  in  10,  and 
in  the  common  duct  alone  in  5. 

Courvoisier  says  that  in  two-thirds  of  the  cases  there  is 
only  one  gall-stone,  and  in  the  remaining  third  they  are 
multiple,  six  being  the  largest  number.  My  experience 
shows  a  much  larger  proportion  of  multiple  calculi  in  the 
common  duct,  and  I  have  removed  as  many  as  eighty-eight 
calculi  from  the  ductus  communis. 

In  67  per  cent,  the  stone  is  in  the  duodenal  end  of  the 
duct,  in  15  per  cent,  in  the  hepatic,  and  in  18  per  cent,  in 
the  middle  portion,  where  it  is  most  easily  reached.  In  about 
a  quarter  of  the  cases  the  duct  was  dilated,  and  in  some  it 
was  cystic  and  the  gall-stone  floating. 

Fenger  has  dwelt  on  the  great  importance  of  the  ball-valve 
action  of  floating  stones  in  the  common  bile-duct,  as  explain- 
ing the  remission  of  jaundice  in  many  cases,  where  it  might 
have  been  supposed  that  the  jaundice  would  be  persistent.  In 
the  greater  number  of  the  cases  of  gall-stones  in  the  common 
duct  given  in  the  Appendix,  the  concretions  were,  though  easily 
moved  by  the  fingers,  too  fixed  to  be  called  floating. 

L  278] 


CALCULI  IN  THE  COMMON  BILE-DUCT  279 

Fenger  explains  the  contracted  condition  of  the  gall- 
bladder, which  is  almost  universally  found  in  cholelithiasis 
by  this  floating  of  gall-stones  in  the  ducts ;  but  as  the  same 
condition  occurs  where  the  gall-stones  are  fixed,  this  explana- 
tion must  be  only  a  partial  one. 

In  a  paper  I  communicated  to  the  Clinical  Society  in  1888, 
and  again  in  my  work  '  On  Gall-stones  and  their  Treatment ' 
(Cassell  and  Co.),  published  in  1892,  attention  was  drawn  to 
this  contraction  of  the  gall-bladder  as  an  important  diagnostic 
point,  and  this  has  been  borne  out  by  other  observers  inde- 
pendently. It  was  then  pointed  out  that  jaundice  with 
distended  gall-bladder  was  presumptive  evidence  in  favour  of 
malignant  disease,  but  that  jaundice  without  distended  gall- 
bladder favoured  the  diagnosis  of  cholelithiasis. 

Of  35  operations  for  obstruction  in  the  common  duct, 
Courvoisier  found  that  18  were  due  to  causes  unconnected 
with  gall-stones,  such  as  cancer,  stricture,  or  tumour  ;  out  of 
these,  the  gall-bladder  was  dilated  in  16,  whereas  only  17 
were  dependent  on  gall-stones,  and  out  of  these  17  the  gall- 
bladder was  atrophied  in  13. 

Whilst  Fenger's  explanation  is  not  all-sufficient  to  account 
for  this  contraction  of  the  gall-bladder,  neither  does  that 
given  by  Courvoisier  fully  explain  it.  He  says  the  contrac- 
tion is  due  to  chronic  inflammation  of  the  walls  of  the  gall- 
bladder, set  up  by  the  stones  when  in  it,  before  they  passed 
into  the  ducts.  This  cannot  account  for  all  cases,  for  in 
some  the  gall-stones  have  never  been  in  the  gall-bladder, 
having  been  formed  in  the  hepatic  or  common  ducts.  The 
condition  is  probably  due  to  a  combination  of  causes  : — 

1.  All  cases  of  cholelithiasis  producing  symptoms  are 
accompanied  by  inflammation  of  the  walls  of  the  biliary 
passages,  as  shown  by  the  almost  universal  presence  of 
adhesions  around  the  gall-bladder. 

2.  Gall-stones  in  the  common  duct  seldom  cause  complete 
obstruction,  either  because  they  are  floating  in  the  duct  or 
because  they  only  partially  fill  it.  There  is,  therefore,  no 
sufficient  backward  pressure  to  cause  dilatation  of  the  gall- 
bladder. 

3.  The    muscular    coat    of   the    gall-bladder    contracts    in 


280    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

efforts  of  expulsion  when   there  is   any  obstruction  in   the 
common  duct. 

4.  The  contraction,  from  being  at  first  intermittent, 
becomes,  in  the  long-run,  constant,  and  the  accompanying 
inflammation  fixing  the  contracted  gall-bladder,  it  atrophies. 

The  special  symptoms  pointing  to  stone  in  the  common 
duct  are :  absence  of  enlargement  of  the  gall  -  bladder, 
with  frequent  attacks  of  pain,  which  is  usually  less 
severe  when  the  gall-stones  are  in  the  common  duct  than 
when  they  are  in  the  cystic  duct,  followed  by  intensi- 
fication of  the  jaundice,  which  in  many  cases  never  quite 
disappears.  The  seizures  are  often  associated  with  inter- 
mittent feverish  attacks,  accompanied  by  rigors  and  loss  of 
weight  and  strength.  The  pain  is  in  the  epigastric  rather 
than  in  the  right  hypochondriac  region,  and  passes  through 
to  the  right  dorsal  or  lumbar,  rather  than  to  the  right  infra- 
scapular,  region,  and  the  tender  point  is  found  between  the 
umbilicus  and  ensiform  cartilage,  rather  than  between  the 
ninth  costal  cartilage  and  umbilicus,  as  in  ordinary  chole- 
lithiasis. 

Jaundice  in  connection  with  gall-stones  in  the  common 
duct  is  a  very  variable  symptom.  In  some  cases  it  is  so 
slight  as  to  be  barely  noticeable,  while  in  others  the  jaundice 
is  the  most  marked  feature.  In  all  cases  of  common  duct 
cholelithiasis  it  varies  from  time  to  time. 

Where  jaundice  is  continuous  and  intense  without  much 
variation,  especially  if  the  gall-bladder  be  enlarged,  there  is 
usually  malignant  disease,  or  some  other  cause  than  gall- 
stones. All  the  other  symptoms  characteristic  of  gall-stones 
may  have  been  present  for  some  time  previously,  or  may  co- 
exist with  those  above-mentioned.  The  following  histories 
illustrate  the  symptoms  usually  associated  with  common 
duct  cholelithiasis  : 

Case  217. — Mrs.  M.  J.,  aged  forty-nine,  seen  with  Dr.  I., 
of  Huddersfield,  May  16,  1898.  History  of  spasms  for  six 
years  ;  then  an  interval  of  six  years  without  any  symptoms. 
In  July,  1897,  began  with  paroxysms  of  pain  over  the  liver, 
which  continued  till  January,  when  jaundice  supervened,  and 
each  attack  of  pain  was  accompanied  by  ague-like  seizures, 


CALCULI  IN  THE  COMMON  BILE-DUCT  28r 

the  jaundice  in  the  interval  diminishing.  Great  loss  of  rlesh  ; 
some  enlargement  of  the  liver ;  no  tumour  of  gall-bladder ; 
slight  jaundice;  some  dilatation  of  the  stomach. 

Operation,  May,  1898. — Pylorus  fixed  to  shrunken  gall- 
bladder, producing  a  kink ;  adhesions  detached ;  no  gall- 
stones in  gall-bladder  or  cystic  duct  ;  several  stones  removed 
from  the  common  duct  by  choledochotomy  ;  duct  sutured ; 
gauze  drainage.     Good  recovery.     Well  several  years  later. 

Case  218. — Mr.  J.  G.,  aged  thirty-nine,  admitted  to  the 
Leeds  General  Infirmary,  May  17,  1898,  suffering  from 
jaundice  of  moderate  intensity.  First  attack  six  and  a  half 
years  ago.  Pain  more  or  less  continuous  since,  and  occa- 
sionally had  severe  paroxysmal  attacks  lasting  twelve  to 
thirteen  minutes.  The  attacks  had  been  accompanied  by 
vomiting  and  rigors,  and  followed  by  jaundice.  He  had  lost 
2  stones  in  weight  since  the  attacks  first  began.  No  tumour 
could  be  made  out.  Gall-bladder  atrophied,  and  could  not 
be  found. 

Operation,  May  19,  1898. — Large  gall-stone  found  impacted 
in  third  part  of  the  common  duct.  Duodenum  incised,  and 
a  stone  the  size  of  a  filbert  removed  from  common  bile-duct 
through  an  incision  in  the  papilla.     Good  recovery. 

Other  cases  will  be  found  in  the  Appendix. 

The  treatment  of  calculous  obstruction  in  the  common 
duct  is  of  the  utmost  interest,  both  on  account  of  the  diffi- 
culties to  be  overcome  and  the  great  importance  to  the 
patient. 

When  once  gall-stones  have  reached  the  common  duct, 
their  attempted  dislodgment  by  purely  medical  means  is, 
with  few  exceptions,  disappointing  in  the  extreme,  and  the 
unfortunate  patients  are  condemned  to  a  lingering  and  painful 
illness,  usually  ending  in  death,  unless  the  obstruction  can  be 
removed  by  surgical  intervention.  Seeing  that  it  is  only 
thirteen  years  since  Courvoisier  first  removed  a  gall-stone 
from  the  common  duct  by  direct  incision,  the  progress  in 
this  branch  of  surgery  must  be  very  pronounced  when  we 
can  safely  affirm  that  there  is  no  portion  of  the  gall-bladder, 
cystic,  common,  or  primary  division  of  the  hepatic  ducts, 
which  cannot,  under  ordinary  circumstances,  be  reached  for 


282    DISEASES  OF  THE  GALL-BLADDER  AND  BILE  DUCTS 

the  removal  of  concretions,  and  that  with  great  probability 
of  success. 

The  following  methods  are  available  for  the  removal  of 
calculi  from  the  common  duct  under  various  conditions : 

(a)  In  a  few  cases,  when  the  cystic  duct  is  dilated,  concre- 
tions may  be  manipulated  backwards  into  the  gall-bladder,  and 
thence  extracted  by  scoop  or  forceps ;  but  this  is  seldom 
practicable  on  account  of  the  contraction  of  the  gall-bladder 
and  cystic  duct  usually  found. 

The  following  case  is  an  example  : 

Case  129. — Mrs.  J.  M.,  aged  thirty-two,  seen  at  the 
General  Infirmary.  Had  suffered  from  attacks  of  biliary 
colic  with  jaundice,  and  after  each  attack  four  or  five  gall- 
stones had  been  passed. 

Operation,  December  3,  1895.  —  Large  numbers  of  gall- 
stones in  the  gall  -  bladder  and  in  the  dilated  cystic  and 
common  ducts.  Cholecystotomy  performed;  129  gall-stones 
removed,  many  being  squeezed  up  from  the  common  duct. 
Good  recovery. 

(b)  Occasionally  a  small  stone  may  be  pressed  into  the 
duodenum,  but  this  is  exceptional,  and  not  generally  to  be 
recommended,  as  not  infrequently  it  may  be  pushed  into  a 
dilated  diverticulum  of  Vater,  and  so  be  missed,  and  the 
whole  operation  rendered  futile. 

Case  No.  480  is  an  example  of  the  successful  manipulation 
of  a  stone  into  the  duodenum,  from  which  it  was  afterwards 
removed. 

(c)  Cholecystotomy,  with  subsequent  treatment  of  the  obstruction 
by  solvent  injections  of  olive  oil  or  soap  solution,  is  well  worth 
bearing  in  mind  in  exceptional  cases  where  patients  are 
extremely  ill — and  the  common  bile-duct  cannot  be  easily 
exposed— on  account  of  its  simplicity  and  safety,  together 
with  the  certainty  of  giving  immediate  relief  with  a  modicum 
of  risk,  and  putting  the  patient  in  better  condition  for  subse- 
quent treatment  should  such  be  necessary.  I  feel,  however, 
bound  to  confess  that  my  experience  of  solvent  injections  has 
not  been  so  favourable  as  to  make  me  very  hopeful  of  accom- 
plishing the  solution  or  the  diminution  to  the  passing-point 
of  the  concretion  deliberately  left  behind,  and  a  subsequent 


CALCULI  IN  THE  COMMON  BILE-DUCT  283 

operation  is  usually  necessary.  This  method  is,  however,  of 
special  value  in  patients  too  ill  to  bear  an  ordinary  operation. 

The  following  is  an  example  : 

Case  179. — Mrs.  E.  A.  N.,  aged  fifty-nine,  seen  at  the 
General  Infirmary,  had  suffered  from  biliary  colic  fourteen 
years  before.  She  had  had  three  or  four  attacks  the  following 
year,  and  then  had  an  interval  of  six  years  without  any  seizures. 
For  the  last  six  weeks  the  patient  had  had  sometimes  two  to 
four  attacks  daily  ;  rigors  and  jaundice  accompanied  each 
attack ;  tumour  present. 

Operation,  May  27,  1897. — Cholecystotomy,  with  removal 
of  numerous  gall-stones  from  the  gall-bladder,  cystic,  hepatic, 
and  common  ducts.  Cholelithotrity  was  peformed  on  six 
stones  which  could  not  be  removed  through  the  gall-bladder 
incision.  After  the  operation  injections  of  olive  oil  were  made 
into  the  gall-bladder  daily  for  several  weeks.  The  patient 
made  a  good  recovery,  and  is  said  to  have  remained  well. 

(d)  Cholelithotrity,  or  crushing  the  stones  in  situ,  where  the 
concretions  are  sufficiently  soft  to  yield  to  the  pressure  of  the 
finger  and  thumb,  is  a  method  of  treatment  which  is  appli- 
cable to  cases  where  the  common  duct  is  difficult  to  reach, 
as  in  very  stout  subjects,  or  where  it  is  desirable  to  avoid 
prolonging  the  operation.  It  is  only  available  in  the  case 
of  soft  concretions,  and  may  have  to  be  supplemented  by 
injecting  the  ducts  with  a  solvent  solution  (see  p.  285, 
Chap.  X.). 

(e)  Needling  concretions  through  the  duct  walls,  recommended 
by  certain  operators,  is  not  unattended  by  danger,  as  the 
damage  to  the  walls  of  the  ducts  may  lead  to  subsequent 
trouble.  It  is  not  necessary  for  soft  stones,  and  uncertain  in 
the  case,  of  hard  concretions. 

(/)  Cholecystenter ostomy ,  or  short-circuiting  the  obstruction, 
may  be  adopted  where  the  patient  is  too  ill  to  bear  a  pro- 
longed operation,  but  it  is  by  no  means  an  ideal  operation, 
as  it  leaves  the  obstruction  untouched.  Since  in  gall- 
stone obstruction  the  gall-bladder  is  usually  contracted, 
cholecystenterostomy  is  impracticable  in  the  greater  number 
of  cases  ;  moreover,  if  immediately  successful,  the  small  open- 
ing is  liable  to  contract  (see  p.  312). 


2S4    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

(g)  Cholcdochcntcrostomy ,  or  uniting  the  dilated  cystic  or 
common  duct  to  the  duodenum,  in  cases  of  largely  dilated 
ducts  with  contraction  of  the  gall-bladder,  may  be  called  for 
on  rare  occasions  (see  p.  197). 

(h)  Choledochostomy,  or  attaching  the  dilated  duct  to  the 
surface  and  draining  it,  is  so  frequently  associated  with 
infection  of  the  ducts  in  the  liver  that  in  a  number  of  the 
cases  reported  a  fatal  result  has  followed.  The  operation  is 
rarely  called  for.     For  examples,  see  p.   197. 

(/)  Cholcdochotomy,  or  incising  the  duct  and  removing  the 
calculi,  is  the  operation  par  excellence  for  the  treatment  of 
gall-stones  in  the  common  ducts  (see  Chap.  XL,  p.  288). 

(j)  Duodeno-choledocliotomy ,  or  reaching  the  duct  through 
the  opened  duodenum  for  stones  impacted  in  the  duodenal 
end  of  the  duct,  is  a  useful  modification  of  the  operation 
(see  p.  295). 

It  will  thus  be  seen  that  in  common  cholelithiasis  the 
surgeon  has  a  great  variety  of  operations  to  choose  from,  and 
he  will  act  the  wisest  who,  knowing  all,  is  able  on  the  spur 
of  the  moment  to  choose  that  peculiarly  adapted  to  the  case 
in  hand. 


CHAPTER  X 
CHOLELITHOTRITY 

CHOLELiTHOTRiTYwas  first  suggested  and  put  in  practice  by 
Lavvson  Tait,  and  has  since  been  extensively  employed  by 
many  surgeons.  The  ordinary  incision  for  cholecystotomy 
may  be  large  enough,  but  if  the  patient  be  stout,  or  the  ducts 
cannot  be  easily  reached,  it  may  have  to  be  increased  so  as 
to  allow  the  hand  to  pass  into  the  peritoneal  cavity,  in  order 
that  the  fingers  may  locate  and  grasp  the  stone  in  situ.  If 
the  right  hand  be  used,  the  thumb  will  enter  the  foramen  of 
Winslow,  and  the  index-finger  will  pass  in  front  of  the 
common  duct ;  or  in  case  of  the  left  hand  being  employed 
these  digits  will  be  reversed,  when  the  whole  force  of  the 
opposing  finger  and  thumb  can  be  brought  to  bear  on  the 
concretion.  Usually  the  gall-stone  flattens  out  into  a  wafer 
shape,  and  by  altering  the  position  of  the  digits  the  edges  of 
the  wafer  are  compressed,  and  the  concretion  is  either  con- 
verted into  pulp  or  breaks  into  innumerable  fragments,  which 
can  be  passed  on  towards  the  duodenum  or  subsequently 
washed  through. 

In  many  cases  of  stones  in  the  common  duct  the  con- 
cretions will  be  found  too  hard  to  crush,  and  it  will  be  neces- 
sary to  perform  choledochotomy. 

The  disadvantages  of  cholelithotrity  are,  first,  the  fear  of 
seriously  damaging  the  duct  by  the  manipulation,  and, 
secondly,  the  danger  of  leaving  fragments  permanently  in 
the  passages,  which  may  then  grow  by  further  deposit  of 
cholesterine. 

The  cases  reported  in  the  Appendix  show  that  the  first 
danger  need  not  be  feared  if  the  finger  and  thumb  only  be 

[  2S5  ] 


286    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

used  as  the  compressing  force  ;  but  if  attempts  are  made  to 
crush  hard  stones  by  instrumental  means,  such  as  padded 
forceps,  suggested  by  Tait,  I  should  think  there  would  be  con- 
siderable danger  of  injuring  the  walls  of  the  biliary  passages. 

In  my  earlier  experience  I  employed  it  in  a  number  of 
cases  with  considerable  success  and  without  any  fatality,  but 
as  fragments  are  apt  to  be  left  behind  and  to  produce  further 
trouble,  I  have  given  up  cholelithotrity  as  a  definite  opera- 
tion, and  only  crush  the  stones  when  I  can  extract  the 
fragments  subsequently  by  means  of  a  scoop. 

The  following  case  is  an  example  : 

Case  505. — Mrs.  S.,  aged  sixty-eight,  seen  with  Dr.  E.,  of 
York.  For  twelve  years  the  patient  had  suffered  from  attacks 
of  biliary  colic  followed  by  jaundice;  lately  the  jaundice  had 
become  deeper  after  the  attacks,  and  there  had  been  con- 
siderable loss  of  flesh.  The  liver  was  slightly  enlarged,  but 
there  was  no  enlargement  of  the  gall-bladder.  Great  tender- 
ness on  pressure  above  and  to  the  right  of  the  umbilicus. 

Operation,  April  28,  1903. — Gall-bladder  shrivelled  and 
contracted.  A  large  gall-stone  the  size  of  a  bantam's  egg 
was  found  in  the  common  duct.  This  was  crushed,  an 
incision  made  into  the  duct,  and  the  fragments  extracted  with 
a  scoop.  The  openings  in  the  gall-bladder  and  the  common 
duct  were  closed  by  sutures,  a  drainage-tube  being  passed  into 
the  right  kidney  pouch.    The  patient  made  a  good  recovery. 

Increased  experience  has  led  me  to  prefer,  the  more  exact 
operation  of  choledochotomy  to  that  of  cholelithotrity,  as  in 
the  latter  there  is  always  the  uncertainty  of  having  left  frag- 
ments too  large  to  pass  the  opening  into  the  duodenum, 
whereas  when  the  duct  is  incised  it  can  be  cleared  with 
almost  absolute  certainty. 

The  danger  of  leaving  fragments  in  the  duct  may  be  over- 
come by  at  the  same  time  performing  cholecystotomy  and 
later  syringing  the  ducts  with  sterilized  water  until  they  are 
clear  of  debris  ;  or,  if  any  fragments  should  be  unavoidably 
left,  by  applying  through  the  fistula  some  solvent  solution. 

In  Case  23,  after  cholecystotomy,  with  crushing  of  calculi 
in  the  common  duct,  the  fragments  did  not  pass  until  a  few 
drops  of  solution  of  turpentine  in  ether  were  injected  into 


CHOLELITHOTRITY  287 

the  fistula  ;  great  pain  followed,  the  duct  became  patent,  the 
fistula  closed,  and  the  patient  has  remained  well  since.  The 
result  in  this  case  was  probably  rather  due  to  the  contractions 
set  up  in  the  duct  than  to  the  solvent  action  of  the  remedy 
used  ;  and  we  cannot,  on  account  of  the  severe  pain  set  up 
for  some  hours,  recommend  its  employment,  though  in  this 
case  the  result  was  good.  A  more  efficient  method  which  we 
now  employ  whenever  there  is  reason  to  think  that  any  of 
the  fragments  remain  in  the  duct  (as  shown  by  the  discharge 
of  bile  continuing  through  the  cholecystotomy  opening 
beyond  the  normal  two  or  three  weeks),  or  wherever  a  gall- 
stone has  been  left  which  could  not  be  crushed,  and  which 
it  was  not  thought  wise  to  remove  by  choledochotomy,  is  to 
syringe  a  warm  0*5  per  cent,  solution  of  sapo  animalis  or 
warm  olive  oil  through  the  fistula  night  and  morning  until 
the  passages  are  quite  free. 

The  olive  oil  and  soap  solution  probably  act  in  a  double 
capacity  as  solvents  and  as  lubricants. 

Dr.  Brockbank  found  that  a  gall-stone  placed  in  a  0*5  per 
cent,  solution  of  sapo  animalis  in  distilled  water,  and  kept  at 
the  body  heat  in  an  incubator,  lost  34  per  cent,  of  its  original 
weight  in  three  weeks,  and  that  a  similar  concretion  in  a 
o*i  per  cent,  solution  lost  14  per  cent,  of  its  weight  in  the  same 
time. 

The  question  of  needling  impacted  concretions  by  the 
passage  of  a  needle  through  the  walls  of  the  ducts  was 
raised  again  by  Mr.  Pridgin  Teale  in  1895.  The  subject  is 
referred  to  in  '  Gall-stones  and  their  Treatment,'  published 
in  1892,  and  this  method  has  been  employed  by  Mr.  Knowsley 
Thornton  ;  it  was  also  fully  discussed  after  a  paper  given 
before  one  of  the  societies,  and  it  was  almost  unanimously 
decided  that  although  concretions  might  be  broken  up  by 
needling,  the  operation  was  inadvisable,  on  account  of  the 
almost  unavoidable  damage  to  the  ducts  and  the  fear  of 
infection. 

It  may,  however,  be  borne  in  mind  that,  if  thought  advis- 
able, some  of  the  very  hard  stones  can  be  broken  up  by 
means  of  a  needle,  and  that  the  fragments  can  be  further 
crushed  between  the  finger  and  thumb. 


CHAPTER  XI 
CHOLEDOCHOTOMY 

Choledochotomy,  or  choledocholithotomy,  is  the  name 
given  to  the  operation  of  incising  the  common  bile-duct  for  the 
extraction  of  gall-stones. 

History.— It  was  first  suggested  by  Langenbach  in  1884, 
though  Kummell  (quoted  by  Fenger)  stated  in  1890  that  he, 
several  years  before,  had  performed  cholecystectomy  on  a 
female  patient  of  forty,  after  which  he  had  removed  a  stone 
the  size  of  a  walnut  from  the  common  duct  through  an  in- 
cision which  he  afterwards  sutured.  The  operation  was  a 
very  prolonged  one,  and  the  woman  died  twenty-four  hours 
afterwards. 

Courvoisier  performed  the  first  successful  operation  on 
January  22,  1890,  and  two  others,  both  successful,  in 
February  and  March  of  the  same  year. 

Since  that  time  it  has  been  done  by  many  surgeons,  and 
at  the  present  time  it  may  be  confidently  asserted  that  there 
is  no  portion  of  the  gall-bladder,  common,  cystic,  or  primary 
divisions  of  the  hepatic  duct,  which  cannot,  under  ordinary 
circumstances,  be  reached  for  the  removal  of  calculi. 

Operation. — The  ideal  operation  for  the  removal  of  stones 
from  the  common  duct  is  choledochotomy,  which,  after  ex- 
perience of  all  the  other  methods,  I  have  come  to  the  con- 
clusion is  the  only  one  to  be  relied  upon,  and  as  an  operation 
is  therefore  worthy  of  special  study.  Moreover,  as  the  result 
of  experience  in  over  100  cases,  I  have  been  able  to  modify 
it  in  such  a  way  that  what  was  formerly  a  most  difficult  pro- 
cedure, involving  prolonged  manipulation,  special  appliances, 
and  at  least  two  assistants,  and  only  to  be  undertaken  after 

L  288  ] 


CIIOLEDOCHOTOMY  289 

all  other  means  had  failed,  is  now  a  comparatively  simple 
operation  in  the  greater  number  of  cases,  only  requiring  the 
help  of  one  assistant,  and  not  requiring  the  use  of  any  special 
apparatus. 

By  this  method  the  time  involved  in  the  operation  is 
reduced  considerably,  and  where  adhesions  do  not  give  un- 
usual trouble,  it  is  easy  to  complete  the  work  in  from  thirty 
to  forty  minutes,  which  not  only  means  a  saving  of  time  and 
fatigue  to  the  operator,  but  a  considerable  saving  of  shock 
to  the  patient.  A  description  of  the  operation  as  since 
modified  is  given  on  p.  249. 

To  those  having  little  experience  in  this  operation,  the 
modifications  may  seem  trivial,  but  to  those  who  have  ex- 
perienced the  difficulties  of  the  ordinary  procedure  I  feel 
sure  that  the  method  described,  which  enables  the  whole  of 
the  bile  passages  to  be  dealt  with  as  a  straight  tube  close  to 
the  surface,  will  be  sufficiently  appreciated. 

It  is  of  the  utmost  importance  to  clear  the  ducts,  or  the 
operation  will  be  futile,  as  shown  by  Kehr,  who  left  con- 
cretions behind  in  16*6  per  cent,  of  his  cases,  and  by  Riedel, 
Terrier,  Fenger,  Lauenstein,  Kuster  and  others.  Fenger  has 
suggested  a  flexible  metallic  probe,  which,  he  says,  will 
give  a  click  when  it  touches  a  stone,  or  which  will  produce 
a  grating  sensation  when  it  passes  one.  This  we  know  by 
experience  to  be  a  fallacious  guide,  as  in  one  case,  after 
carefully  probing  and  even  passing  a  scoop  into  both  hepatic 
ducts,  and  up  and  down  the  common  duct,  without  feeling  a 
calculus,  a  finger  inserted  through  the  incision,  felt  a  stone, 
which  was  then  removed  ;  but  had  we  trusted  to  a  probe,  the 
calculus  would  have  been  left.  The  duct  is  usually  dilated 
sufficiently  to  permit  digital  exploration,  which,  under  such 
circumstances,  we  should  always  advise,  reserving  a  bent 
probe,  or,  better  still,  a  slender,  bent  scoop,  for  use  where  the 
duct  is  not  capacious  enough  for  the  finger.  The  hepatic 
duct  and  its  primary  branches  can  be  readily  explored,  and 
in  Cases  217,  etc.,  calculi  were  removed  from  them  through  an 
incision  in  the  common  duct. 

If  gall-stones  be  found  in  the  hepatic  duct,  they  may  be 
reached  by  opening  the  common  duct  and  passing  a  scoop 

19 


290    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

or  forceps  through  this  opening,  or,  if  needful,  the  hepatic 
duct  may  be  incised  and  the  concretions  removed,  as  in  Cases 
35,  440,  and  508. 

Dr.  Elliott,  of  Boston,  recommends  the  application  of  the 
sutures  before  removing  the  stone,  and  if  interrupted  stitches 
are  employed  this  is  certainly  an  advantage,  though  if  the 
ducts  have  to  be  explored  afterwards  the  sutures  are  rather 
in  the  way. 

The  same  advantages  may  be  obtained  by  introducing  the 


Fig.  6G. — Diagram  to  illustrate  the  First  Sutures  in  Choledochotomy 

two  end  stitches  before  extracting  the  calculus,  as  when  they 
are  drawn  on,  the  edges  are  approximated  and  more  easily 
sutured  (Fig.  66).  It  will,  however,  be  seen  that  I  prefer 
continuous  sutures,  and  these  I  do  not  apply  until  I  have 
cleared  the  ducts. 

Professor  Halstead  (Johns  Hopkins  Hospital  Bulletin,  1898) 
advocates  the  use  of  a  small  hammer  which  he  has 
devised  for  facilitating  the  application  of  sutures  in  the 
repair  of  the  common  bile-duct.  By  expanding  the  duct 
and  drawing  it  towards  the  surface,  it  not  only  temporarily 


CHOLEDOCHOTOMY  291 

blocks  the  passage,  but  allows  the  sutures  to  be  accurately 
applied.  I  have  never  found  need  to  use  this  instru- 
ment, but  it  has  been  found  useful  by  its  author  and 
others. 

Drainage  through  a  stab  wound  in  the  right  loin,  or  by 
means  of  a  split  tube  inserted  by  the  side  of  the  gall-bladder 
tube,  is  an  efficient  means  of  draining  the  discharge  from  a 
leaking  gall-bladder  or  bile-duct,  since  there  is  a  distinct 
peritoneal  pouch,  bounded  above  by  the  right  lobe  of  the 
liver,  below  by  the  ascending  layer  of  the  transverse  meso- 
colon covering  the  duodenum  internally,  externally  by  the 
parietal  peritoneum,  and  internally  by  the  peritoneum  cover- 
ing the  right  side  of  the  vertebral  column,  and  passing  up  to 
the  foramen  of  Winslow  (Fig.  68,  p.  292). 

Morison  {British  Medical  Journal,  November  3,  1894)  has 


Fig.  67. — Halstead's  Miniature  Hammer,  for  Use  in  suturing  the 

Bile-duct,     (ii  sizes.) 

found  it  to  be  capable  of  holding  nearly  a  pint  before 
it  overflows  into  the  general  peritoneal  cavity.  He  advo- 
cates drainage  of  this  pouch  and  non-suture  of  the  ducts 
if  'there  be  any  difficulty  in  securing  the  margins  of  the 
opening. 

Mr.  Frederick  Page  {Lancet,  December  5,  1896),  on  the 
other  hand,  advocates  careful  suture  of  the  opening  in 
the  duct,  and  closing  the  abdomen  without  leaving  in  a 
drainage-tube.  He  gives  four  cases  in  support  of  his 
views. 

The  late  Mr.  Greig  Smith  said  that  drainage  is  always 
advisable,  and  in  this  view  we  fully  agree,  as  although  we  are 
usually  confident  of  securing  accurate  suture  of  the  opening 
in  the  duct,  yet  in  one  or  two  of  the  earlier  cases  a  bile- 
stained  discharge  from  the  tube  showed  the  need  of  a  drain; 
and  it  must  be  borne  in  mind  that,  although  the  ducts  appear 

19 — 2 


292    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

to  be  clear,  it  is  impossible  to  be  absolutely  certain,  as  was 
proved  in  Case  141,  where,  under  the  supposition  that  the 
common  duct  had  been  effectually  cleared,  a  shrivelled  and 
mutilated  gall-bladder  was  removed  and  the  cystic  duct 
ligatured,  with  the  result  that  septic  bile  became  extravasated 
into  the  peritoneal  cavity.  A  small  gall-stone  was  found 
obstructing  the  orifice  of  the  duct,  where  it  was  opening  into 
the  duodenum.  The  same  difficulty  was  experienced  in  one 
of  Fenger's  and  in  several  of  Kehr's  cases. 


Fi  j.  68. — Transverse  Section  through  Centre  of  Pouch  described. 

The  following  are  examples  of  choledochotomy  : 
Case  398. — Choledochotomy. — A  man,  aged  fifty- three  years, 
who  was  seen  at  the  Leeds  General  Infirmary,  had  had  colic 
for  twelve  years  and  jaundice  for  two  years,  the  jaundice 
having  been  very  deep  for  some  time.  On  October  10, 1901, 
choledochotomy  was  performed  in  the  manner  previously 
described,  and  a  stone  was  removed  from  the  common  duct. 
The  patient  returned  home  within  the  month  and  was  well 
when  seen  in  December,  1901. 

Case  400. — Choledochotomy. — A  man,  aged  fifty-eight  years, 
was  seen  with  Dr.  R.,  of  Preston.  He  had  had  very  deep 
jaundice  for  three  years.  Biliary  cirrhosis  and  ascites  as  well 
as  jaundice  were  present,  and  there  was  a  stone  in  the  common 


CHOLEDOCHOTOMY  293 

duct.  On  October  21,  1901,  choledochotomy  was  performed 
and  the  omentum  was  fixed  to  the  anterior  abdominal  wall, 
in  order  to  cure  the  ascites.  Anterior  drainage  was  employed. 
In  December,  1901,  I  had  a  letter  to  say  that  he  was  regain- 
ing strength  and  feeling  well,  and  I  am  told  that  he  has  com- 
pletely regained  his  health.  In  June,  1903,  he  was  well,  and 
had  had  no  return  of  ascites. 

The  following  are  examples  of  removal  of  calculi  from  the 
hepatic  duct : 

Case  406. — Calculi  in  the  Gall-bladder  and  in  the  Hepatic  and 
Common  Bile-ducts — Choledochotomy — Recovery. — A  policeman, 
aged  forty-eight,  a  stout,  unhealthy  subject,  with  a  history  of 
former  intemperance,  had  suffered  from  gall-stones  for  twenty 
years,  and  from  jaundice  with  infective  cholangitis  since  May, 

1901.  On  December  7, 1901,  choledochotomy  was  performed 
in  the  infirmary,  when  1 26  gall-stones  were  removed  from  the 
gall-bladder,  and  88  from  the  common  and  hepatic  ducts. 
Recovery  was  retarded  by  bronchitis,  but  the  patient  was 
discharged  in  five  weeks,  and  has  remained  well. 

Case  451. — Calcidi  in  Gall-bladder  and  in  the  Common  and 
Hepatic  Ducts  —  Choledochotomy  —  Recovery.  —  On  July  17, 

1902,  I  operated  on  a  lady,  aged  seventy,  and  removed  a 
considerable  number  of  gall-stones  from  both  arms  of  the 
hepatic  duct,  after  clearing  the  common  duct  of  concretions 
through  a  choledochotomy  opening.  The  patient  is,  I  am 
informed,  now  quite  well. 

In  some  cases  the  common  bile-duct  is  found  dilated  to  the 
size  of  the  small  intestine,  and  if  the  gall-bladder  and  cystic 
duct  are  small,  and  so  contracted  as  to  be  useless  for  drainage, 
a  firm  rubber  tube  is  inserted  into  the  incision  in  the  duct 
and  pushed  a  little  way  up  into  the  hepatic  duct.  The  tube 
being  surrounded  by  a  purse-string  suture,  and  nxed  in 
position  by  one  or  two  catgut  stitches,  as  in  the  following  case  : 

Case  394. — Choledochotomy — Drainage — Recovery. — I  saw 
the  patient,  a  man,  aged  fifty-one,  with  Dr.  H.,  of  Upwell. 
There  had  been  only  slight  colic,  but  for  a  year  deep  jaundice, 
with  great  wasting  and  infective  cholangitis.  Choledocho- 
tomy was  performed  on  September  29,  1901,  five  stones 
being  removed  from  the  common  duct.     As  there  was  chronic 


294    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

pancreatitis,  the  dilated  common  duct  was  drained  by  means 
of  a  rubber  tube  fixed  in  by  a  stitch  of  catgut,  and  surrounded 
by  a  purse-string  suture.  A  lumbar  drain  was  also  inserted, 
but,  as  events  proved,  this  was  unnecessary.  The  patient  was 
very  well  and  had  gained  I  stone  3  pounds  in  weight  by 
November,  1901.  He  remained  well  when  heard  of  in 
June,  1902. 

Statistics. — As  this  is,  perhaps,  the  most  difficult  and 
prolonged  of  the  operations  on  the  bile  -  ducts,  the 
mortality  is  necessarily  greater  than  that  of  simple  chole- 
cystotomy.  In  1892  Martig  had  collected  27  cases,  and  in 
1895  Mermann  17  others,  giving  a  total  of  44  cases,  with  a 
mortality  of  18  per  cent.  Terrier  (British  Medical  Journal 
Supplement,  January  7,  1893),  in  1892,  had  collected  20  cases, 
with  a  mortality  of  25  per  cent.  Hans  Kehr  (Berlin  Klin. 
Woch.,  June,  1896)  collected  from  various  sources  84  cases  of 
choledochotomy,  with  31  deaths,  giving  a  mortality  of  37*8 
per  cent.  Even  excluding  severe  cases,  the  mortality  was 
25  per  cent.,  though  in  his  own  practice  the  death-rate  was 
only  6*6  per  cent.  In  a  later  series  (Langenbeck's  Archives, 
vol.  lviii.,  Part  3)  his  mortality  was  12*5  per  cent. 

He  remarks :  *  The  operation  involves  many  difficulties, 
which  can  only  be  overcome  by  one  performing  a  large 
number  of  operations,  and  even  then  it  is  not  very  easy  to 
remove  all  the  concretions.  Out  of  30  cases,  in  5  all  the 
stones  were  not  removed,  in  3  the  operation  was  repeated, 
and  in  2  cases  the  wound  reopened  and  gave  exit  to  the 
calculi  that  had  been  left.  Fenger  has  reported  7  cases,  of 
which  1  died,  giving  a  mortality  of  14*3  per  cent. 

Dr.  W.  J.  Mayo,  of  Rochester,  Minnesota,  gave  a  paper 
in  May,  1903  (Boston  Medical  and  Surgical  Journal,  May  21, 
1903),  and  reported  having  performed  59  choledochotomies, 
of  which  3  died,  which  gives  a  mortality  of  5*08  per  cent. 

My  own  experience  in  this  operation  has  been  very  inter- 
esting, for  of  the  37  cases  operated  on  up  to  July,  1901, 
4  died,  giving  the  rate  of  mortality  of  16*2  per  cent.,  whereas 
out  of  the  operations  since  July,  1901,  51  in  number,  I  have 
only  lost  1,  thus  giving  a  rate  of  mortality  of  1*9  per  cent. ; 
and  I  have  had  a  consecutive  series  of  52  choledochotomies 
and  duodeno-choledochotomies  without  a  death. 


CHOLEDOCHOTOMY  295 

DUODENO-CHOLEDOCHOTOMY. 

Duodeno-choledochotomy  is  a  term  applied  to  the  modifi- 
cation of  the  operation  of  choledochotomy,  in  which  the  gall- 
stones are  removed  from  the  common  duct  through  an  incision 
in  the  duodenum.  Duodeno-choledochotomy  was  first  per- 
formed by  Dr.  McBurney  (A  finals  of  Surgery,  October  18, 1893), 
next  by  Professor  Kocher  (Korresp.f.  Sch.  Hertze,  1895,  No.  7), 
and  I  believe  that  Case  182  was  the  first  performed  in  this 
country  (British  Medical  Journal,  November  5,  1898). 

Statistics. — I  have  performed  15  duodeno-choledochotomies 
with  recovery  in  12,  the  last  9  cases  having  all  recovered. 

Operation. — The  operation  is  really  less  difficult  than  it  would 
appear,  and  is  much  facilitated  by  placing  a  sandbag  under 
the  lower  dorsal  spines.  Where  the  liver  is  small  and  the 
common  duct  cannot  be  made  to  reach  the  surface,  its 
exposure  through  the  duodenum  may  be  simpler  than  the 
ordinary  operation  of  choledochotomy.  The  termination  of 
the  common  duct,  including  the  duodenum,  should  be  grasped 
between  the  finger  and  thumb  of  the  left  hand,  and  the 
anterior  wall  of  the  gut  cut  through,  thus  exposing  the 
interior  of  the  posterior  wall  of  the  intestine  with  the  termina- 
tion of  the  common  duct  running  in  it  (see  Anatomy,  p.  10). 
Either  the  duct  can  be  laid  open  from  the  papilla,  or  the 
stone  may  be  cut  down  on  through  the  posterior  wall  of  the 
duodenum.  Bile  flows  freely  as  soon  as  the  obstruction  is 
removed,  and  it  must  be  mopped  away  as  it  flows,  since  it 
always  contains  pyogenic  microbes,  and  is  therefore  infective. 
As  a  rule,  there  will  be  no  trouble  with  bleeding,  and  no 
sutures  need  be  placed  in  the  posterior  wall  of  the  duodenum. 
The  incision  through  which  the  duodenum  has  been  opened 
should  be  sutured  by  a  continuous  catgut  suture  for  the 
mucous  membrane  and  a  continuous  silk  or  celluloid  thread 
suture  for  the  peritoneum. 

For  calculi  impacted  in  the  diverticulum  of  Vater,  the 
operation  is  preferable  to  the  ordinary  choledochotomy,  as  it 
is  occasionally  difficult  to  extract  a  stone  impacted  in  the  am- 
pulla through  an  incision  in  the  supraduodenal  portion  of  the 
common  duct ;  moreover,  an  incision  of  the  narrow  orifice  of 


296    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

the  bile-duct  in  the  duodenum  leaves  a  patent  opening,  which 
will  allow  any  other  concretions  that  may  have  escaped 
observation  to  pass  without  difficulty. 

This  method  of  reaching  the  common  duct  will  in  all  prob- 
ability be  practised  more  frequently  than  hitherto  now  that 
its  safety  and  practicability  have  been  established. 

It  is  available  not  only  for  gall-stone  obstruction,  but  also 
for  jaundice  depending  on  cancer  of  the  opening  of  the 
common  bile-duct  (see  p.  211),  or  on  stricture  (Case  436, 
p.  115),  and  for  obstruction  of  the  orifice  of  the  pancreatic 
duct. 

Some  years  ago  I  suggested  the  feasibility  of  exploring  the 
pancreatic  duct  by  this  route,  and  in  February  of  this  year  I 
removed  a  pancreatic  calculus  in  this  way  (Case  487). 

Zeller  (Berlin  Klin.  Woch.,  September  1,  1902)  reported  a 
case  in  which  he  operated  for  obstructive  jaundice,  and,  fail- 
ing to  find  a  calculus  in  the  bile-ducts,  although  he  palpated 
from  without  from  the  duodenum  and  from  the  pancreas,  he 
made  a  diagnosis  of  malignant  disease  of  the  pancreas,  as 
there  was  a  hard  nodular  mass  in  the  head  of  that  organ. 
The  patient  died  six  days  after  the  operation,  and  at  the 
necropsy  he  found,  on  passing  a  probe  through  the  papilla, 
after  opening  the  duodenum,  a  calculus  about  the  size  of  a 
hazel-nut.  Since  then  he  has  always  opened  the  duodenum 
and  passed  a  probe  through  the  papilla  if  he  failed  to  find  a 
calculus  on  searching  along  the  course  of  the  ducts.  He 
says  that  at  times  it  is  easier  to  dislodge  the  calculus  by  pass- 
ing the  sound  backwards  through  the  common  duct  than 
downwards  from  the  gall-bladder,  and  is  of  opinion  that 
the  operation  is  in  many  cases  preferable  to  choledochotomy. 

The  following  cases  are  given  as  examples,  and  others  will 
be  found  in  the  Appendix  : 

Case  354. — Duodcno-Choledochotomy. — Mrs.  G.,  aged  thirty- 
eight,  was  seen  by  me  at  the  General  Infirmary.  There 
had  been  colic  and  jaundice  for  six  months,  with  loss  of 
weight  and  strength.  Deep  jaundice  was  present ;  there 
were  gall-stones  in  the  common  duct.  Duodeno-choledocho- 
tomy,  performed  on  January  31,  1901,  resulted  in  a  good 
recovery,  and  the  patient  was  well  some  months  later. 


CHOLEDOCHOTOUY  297 

Case  363. — Duodcno-choledochotomy — Recovery. — A  woman, 
aged  forty-nine,  was  seen  at  the  General  Infirmary.  For  six 
years  colic  had  persisted,  with  varying  jaundice.  On 
March  22,  1901,  duodeno-choledochotomy  was  performed, 
and  eight  large,  together  with  numerous  small,  gall-stones 
were  removed  from  the  common  duct.  A  good  recovery 
ensued,  the  patient  being  well  some  months  later. 

RETRODUODENAL  CHOLEDOCHOTOMY. 

Berg  {Centralbl.  f.  Chir.,  No.  27,  1903)  points  out  that 
McBurney's  method  of  removing  an  impacted  calculus  from 
the  retroduodenal  portion  of  the  ductus  communis  through 
an  incision  made  into  the  lumen  of  the  duodenum  is  difficult 
and  not  free  from  danger.  It  is  not  always  possible  to  find 
the  duodenal  papilla  of  the  duct,  and,  beyond  the  slight  risk 
of  primary  peritoneal  infection,  there  is  the  serious  and  more 
likely  one  of  the  formation  of  an  external  duodenal  fistula. 
The  author  describes  the  different  steps  of  an  operation  which 
he  has  practised  to  his  full  satisfaction  on  the  cadaver.  This 
consists  in  making  a  vertical  incision  through  the  posterior 
parietal  peritoneum  on  the  right  side  of  the  descending 
portion  of  the  duodenum,  so  as  to  mobilize  this  portion 
of  the  intestine  and  to  render  it  capable  of  being  moved  over 
towards  the  left  side  of  the  abdomen,  and  also  of  being 
rotated  in  the  same  direction.  By  this  rotation  the  posterior 
surface  of  the  intestine,  together  with  the  retroduodenal  and 
papillary  portions  of  the  ductus  communis,  may  be  brought 
forward  and  freely  exposed  to  view.  The  duct,  it  is  stated, 
can  be  readily  recognised  when  thus  exposed,  and,  whilst 
retained  between  the  surgeon's  fingers,  be  incised  for  the 
release  of  any  impacted  body. 

H epato-doclwtomy . — This  operation  of  directly  incising  the 
hepatic  duct  for  the  removal  of  gall-stones  may  be  conveni- 
ently termed  hepato-dochotomy.  It  differs  in  no  respect 
from  choledochotomy,  except  that  the  hepatic  duct  is  incised 
instead  of  the  common  duct,  the  operation  having  been 
rendered  possible  by  the  more  complete  exposure  obtained 
by  the  method  described  on  p.  249.  Cases  35,  440  and  50S 
are  examples. 


CHAPTER  XII 

CHOLECYSTECTOMY 

Cholecystectomy,  or  excision  of  the  gall-bladder,  may  be 
required — 

i.  In  bullet-wound  or  other  wound  of  the  gall-bladder 
where  suture  is  impracticable. 

2.  In  stricture  of  the  cystic  duct. 

3.  In  phlegmonous  cholecystitis  and  in  gangrene  of  the 
gall-bladder. 

4.  In  multiple  or  in  perforating  ulcers. 

5.  In  chronic  cholecystitis  from  gall-stones,  where  the 
gall-bladder  is  shrunken  and  too  small  to  safely  drain,  or 
where  it  is  enlarged,  thickened,  and  ulcerated,  the  common 
duct  being  free  from  obstruction. 

6.  In  mucous  fistula  due  to  stricture  of  the  cystic  duct. 

7.  In  hydrops  of  the  gall-bladder  due  to  stricture  of  the 
cystic  duct,  as  also  in  certain  other  cases  where  the  gall- 
bladder is  very  much  dilated. 

8.  In  certain  cases  of  empyema,  where  the  walls  of  the 
gall-bladder  are  seriously  damaged. 

9.  In  cancer,  where  the  disease  is  limited  to  the  gall- 
bladder or  to  the  immediately  adjoining  parts,  and  where 
there  is  no  evidence  either  of  extensive  glandular  infection  or 
of  secondary  growths  in  the  liver  or  elsewhere. 

10.  In  certain  other  solid  tumours  of  the  gall-bladder, 
whether  inflammatory  or  due  to  neoplasm. 

11.  In  calcareous  gall-bladder. 

The  operation  varies  in  its  extent  and  in  character  accord- 
ing to  the  disease  for  which  it  has  to  be  undertaken,  but  in 
all  cases  it  may  be  carried  out  through  the  usual  incision  for 
reaching  the  gall-bladder. 

[  29S  ] 


CHOLECYSTECTOMY  299 

For  malignant  disease  cholecystectomy  has  been  performed 
on  numerous  occasions,  and  with  an  encouraging  amount  of 
success.  We  have  related  several  examples  in  the  chapter 
on  Tumours,  p.  186.  In  these  cases  not  only  must  the  gall- 
bladder itself  be  freely  excised,  but  it  may  be  necessary  to 
remove  a  portion  of  the  liver  adjoining  the  gall-bladder  or  an 
elongated  right  hepatic  lobe  ;  or  it  may  be  advisable  even  to 
perform  pylorectomy  or  enterectomy  at  the  same  time.  The 
operation  may  be  performed  by  cutting  instruments,  by 
Paquelin's  cautery,  or  by  means  of  the  elastic  ligature. 

A  reference  to  the  list  of  cases  in  the  Appendix  will  show 
that  there  were  12  cholecystectomies  for  malignant  disease, 
of  which  9  recovered,  one  patient  being  at  the  present  time 
in  good  health,  four  years  and  another  three  years  after 
operation. 

Examples  of  removal  by  the  elastic  ligature  and  by  incision 
follow,  and  others  will  be  found  on  p.  186. 

Case  273. — Excision  of  Cancer  of  Liver  and  Gall-bladder — 
Recovery. — A  man,  aged  forty-six,  had  suffered  for  seven  years 
from  gall-stone  attacks  and  infective  cholangitis.  Loss  of 
4  stones  in  weight;  jaundice. 

Operation,  June  26,  1899. — Tumour  of  liver  adjoining  gall- 
bladder excised  by  wedge-shaped  incision.  Fundus  of  gall- 
bladder also  removed.  Large  number  of  gall-stones  removed 
and  cholecystenterostomy  performed.  Complete  and  perfect 
recovery.  Patient  in  excellent  health  at  the  present  time, 
over  four  years  subsequent  to  operation. 

Microscope  showed  disease  removed  to  be  cancer. 

Case  330. — Excision  of  Cancer  from  Liver,  Gall-bladder,  and 
Pylorus — Recovery. — A  woman,  aged  sixty-three  ;  history  of 
pain  and  jaundice  ;  great  loss  of  flesh  and  strength  ;  tumour 
in  gall-bladder  region. 

Operation,  August  10,  1900. — Mass  of  growth  discovered  in 
liver,  gall-bladder,  and  pylorus.  Cholecystectomy,  pylorec- 
tomy, and  partial  hepatectomy  performed.  Good  recovery. 
Patient  well  and  in  good  health  now. 

Microscopic  examination  showed  the  disease  to  be  cancer. 

But  these  are  exceptional  cases,  as  there  were  no  secondary 
manifestations  of  disease  in   the   liver   or  elsewhere.     Had 


300    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

there  been  such,  I  should  have  simply  concluded  the  opera- 
tion as  an  exploratory  one. 

The  following  case  is  an  example  of  the  cautery  operation, 
under  the  care  of  Dr.  W.  J.  Mayo,  of  Rochester,  Minn.  : 

Mrs.  E.  R.,  aged  sixty-five,  was  admitted  to  St.  Mary's 
Hospital,  Rochester,  Minn.,  April  18,  1900. 

History. — She  has  been  in  her  usual  health  until  within  the 
past  six  months.  During  this  time  she  has  suffered  from  a 
boring  pain  in  the  right  side,  which  has  of  late  become  almost 
constant.  Stomach  symptoms  have  been  of  moderate 
severity.  There  has  been  some  loss  of  appetite  and  con- 
stipation, with  a  decrease  of  15  pounds  in  weight.  Neither 
jaundice  nor  history  of  colic.  Examination  reveals  a  some- 
what movable  tumour  in  the  right  hypochondriac  region,  evi- 
dently connected  with  the  liver.   The  mass  has  a  nodular  feel. 

Operation,  April  21,  1900. — Exploratory  incision.  A  car- 
cinomatous gall-bladder  involved  the  adjacent  portion  of  the 
liver  and  the  cystic  duct.  There  was  some  infiltration  along 
the  common  duct,  and  extending  to  the  duodenum  at  one 
place  was  a  considerable  area  of  adhesions.  A  few  glands  in 
the  angle  between  the  cystic  and  hepatic  ducts  were  infected. 
The  disease  was  so  definitely  circumscribed,  with  such  slight 
glandular  involvement,  that  its  removal  was  decided  on.  The 
excision  was  begun  at  the  common  duct,  2  inches  of  which 
was  removed  with  1  inch  of  the  hepatic  duct.  The  vessels 
were  caught  and  tied  as  divided ;  an  area  of  adherent 
duodenum  the  size  of  a  silver  dollar  was  included  in  the 
excision.  The  opening  in  the  intestine  was  closed  by  circular 
purse-string  sutures.  The  lower  end  being  thus  freed,  the 
gall-bladder  with  the  attached  liver  was  removed  with  the 
Paquelin  cautery  knife.  The  larger  vessels  were  grasped 
with  forceps.  The  free  venous  oozing  from  the  liver  sub- 
stance was  not  controlled  by  the  cautery,  although  easily 
checked  by  slight  pressure,  the  blood  current  being  of  little 
force.  A  piece  of  sterile  gauze  the  size  of  the  wrist  was 
placed  in  the  cavity,  and  a  continuous  suture  of  fine  catgut 
was  run  through  the  liver  substance  on  each  side  of  and 
around  the  gauze,  compressing  the  bleeding  liver  margins 
against  it,  and  controlling  the  haemorrhage  efficiently.     The 


CHOLECYSTECTOMY  301 

portal  vein  was  exposed  to  a  considerable  extent  in  the 
bottom  of  the  cavity.  Adequate  drainage  was  afforded,  the 
bile  being  conducted  to  the  surface.  Recovery  was  un- 
eventful. The  gall-bladder  contained  a  single  stone  \  inch 
in  diameter. 

For  benign  neoplasms  complete  cholecystectomy  has  rarely 
been  undertaken.  Terrier  gives  three  cases  by  Adler,  Ricard, 
and  Rontier,  all  of  which  recovered.  In  all  these  cases  the 
tumours  were  cystic  or  inflammatory,  and  associated  with 
gall-stones. 

In  one  case  of  complete  cholecystectomy  under  my  care 
the  growth,  which  was  thought  to  be  a  neoplasm,  turned  out 
on  microscopic  examination  to  be  inflammatory  (Case  234). 

The  following  is  an  example  of  cholecystectomy  for  the 
removal  of  a  calcareous  gall-bladder  : 

Case  375. — Mrs.  W.,  aged  fifty-seven,  seen  with  Dr.  M., 
of  Bolton,  for  repeated  attacks  of  biliary  colic,  associated 
with  jaundice  of  three  weeks'  standing  and  rapid  loss  of  flesh. 

Operation,  June  8,  190 1,  when  a  gall-stone  was  found  in  the 
common  duct,  and  one  in  a  calcareous  gall-bladder  the  shape 
and  size  of  a  hen's  egg.  Choledochotomy  and  cholecystec- 
tomy were  performed  and  followed  by  a  smooth  recovery,  the 
patient  being  quite  well  in  September,  T901. 

Simple  cholecystectomy  may  be  performed  by  three  different 
methods,  it  being  an  important  proviso  that  the  common  duct 
is  cleared  of  concretions  and  freely  patent. 

It  may  be  completely  taken  away  by  dissecting  it  from  its  bed 
or  by  shelling  it  out,  the  cystic  duct  being  used  as  a  pedicle 
and  ligatured.  When  the  gall-bladder  is  very  much  con- 
tracted this  is  both  easy  and  safe,  as  the  attachments  to  the 
liver  are  readily  dissected  off  without  tearing  the  liver  sub- 
stance. A  method  of  treating  the  pedicle,  otherwise  the 
cystic  duct,  which  I  have  found  effectual,  but  which,  to  the 
best  of  my  belief,  has  not  been  adopted  by  others,  is  worth 
mentioning.  The  duct  is  seized  with  strong  pressure  forceps 
and  crushed,  thus  making  a  groove  in  which  the  ligature, 
preferably  of  catgut,  lies  quite  snugly.  Any  vessels  that 
bleed  are  ligatured,  and  as  a  matter  of  precaution  (for  the 
parts  being  dealt  with  are  necessarily  infected)  a  strip  of 


3o2    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

iodoform  gauze  is  left  in  contact  with  the  end  of  the  ligatured 
duct,  and  brought  to  the  surface  through  a  split  drainage- 
tube.     The  following  case  affords  an  example : 

Case  22. — Removal  of  Gall-stone — Persistent  Fistula — Chole- 
cystectomy— Recovery. — Mrs.  S.  G.,  aged  forty-nine,  operated 
on  in  1888  for  gall-stones  (when  sixty-six  small  ones  were 
removed  from  a  contracted  and  ulcerated  gall-bladder  and 
cystic  duct),  was  left  with  a  mucous  fistula,  which  had  to  be 
kept  open  by  a  tube,  as  if  it  was  allowed  to  heal  pain  and  fever 
resulted.  On  May  14, 1890,  a  further  operation  was  performed, 
when  the  gall-bladder  was  found  shrivelled  and  adherent  and 
the  cystic  duct  was  strictured.  The  operation  of  cholecys- 
tectomy was  performed,  and  a  complete  recovery  resulted,  the 
patient  being  well  when  heard  of  several  years  later. 

The  second  method  is  applicable  to  cases  where  the  gall- 
bladder is  larger,  but  in  which  it  is  so  seriously  damaged 
as  to  be  unsafe  to  leave  it,  or  in  cases  where,  owing  to 
impaction  of  a  concretion  in  the  cystic  duct,  ulceration  has 
occurred,  and  may  be  followed  by  stricture,  which  would 
both  prevent  the  gall-bladder  performing  its  function  as  a 
reservoir  for  bile,  and  might  lead  to  an  accumulation  of 
mucus  and  the  formation  of  a  tumour. 

In  this  case  the  attachment  to  the  liver  is  considerable, 
and  if  the  gall-bladder  be  fully  detached,  laceration  of  the 
liver  and  troublesome  bleeding  are  apt  to  occur,  which  can  be 
saved  by  making  a  longitudinal  incision  through  the  serous 
and  fibrous  coats  on  each  side  of  the  liver  attachment,  when 
the  bulk  of  the  gall-bladder  and  all  the  mucous  membrane 
can  be  removed,  necessitating  only  ligature  of  branches  of  the 
cystic  artery  in  the  small  portion  of  the  fibrous  coat  left 
attached  to  the  liver.  The  cystic  duct  may  then  be  ligatured, 
as  described  in  the  last  operation,  or  plugged  with  a  gauze 
drain,  or  drained  by  the  insertion  of  a  tube  which  is  sur- 
rounded by  a  purse-string  suture,  so  as  to  prevent  leakage  of 
bile.     The  following  cases  afford  examples  : 

Case  hi. — Cholecystectomy — Recovery. — Mr.  M.,  aged  forty- 
six,  seen  with  Dr.  R ,  of  New  York,  and  Dr.  G.,  of  Nice,  for 
frequent  seizures  of  intense  pain  resembling  biliary  colic, 
with  irregular  fever  and  great  loss  of  flesh  and  strength. 


CHOLECYSTECTOMY  303 

At  the  operation  on  May  2,  1895,  I  found  an  inflamed  and 
contracted  gall  -  bladder,  with  cholangitis  and  extensive 
adhesions,  doubtless  due  to  gall-stones  that  had  passed. 
After  opening  the  gall-bladder  and  clearing  away  muco-pus, 
the  organ  was  excised  in  the  way  just  described,  and  the  duct 
was  plugged  with  gauze  brought  to  the  surface  through  a 
tube.  Recovery  was  uninterrupted,  and  he  was  able  to 
sail  at  the  month  end.  Nine  months  later  he  was  in  perfect 
health. 

Case  299. — Gangrene  of  Gall-bladder — Partial  Cholecystec- 
tomy— Recovery. — Mr.  M.  A.,  aged  fifty,  seen  with  Dr.  A.,  of 
York,  January  10,  1900,  for  acute  local  peritonitis  of  a  week's 
duration,  starting  in  the  region  of  the  gall-bladder,  and 
ushered  in  by  a  rigor,  followed  by  fever  and  intense  pain  and 
prostration,  the  first  symptom  of  pain  in  the  gall-bladder 
region  having  only  been  noticed  a  month  previously. 

The  operation  was  performed  the  same  day,  when  gangrene 
of  the  fundus  of  the  gall-bladder  was  discovered,  with  intense 
local  peritonitis,  limited  by  acutely  inflamed  and  darkened 
omentum,  the  patient  being  a  very  fat  subject.  Cholecystec- 
tomy performed  ;  the  portion  attached  to  the  liver  was  left, 
as  it  was  not  gangrenous.  A  tube  was  inserted  into  the 
cystic  duct.  He  made  an  uninterrupted  recovery,  and  is 
.  now  in  excellent  health. 

Dr.  W.  Mayo,  of  Rochester,  U.S.A.,  suggested  another 
method  of  partial  cholecystectomy  which  he  has  found  of 
service.  He  lays  open  the  gall-bladder  and  shells  out  the 
mucous  membrane,  if  possible  in  one  piece,  plugging  the 
cavity  remaining  with  gauze.  In  some  cases  this  is  easy,  but 
in  others,  where  there  has  been  much  inflammatory  disturb- 
ance, I  have  found  it  impracticable. 

In  certain  cases  of  greatly  enlarged  and  in  hourglass- 
shaped  gall-bladder  the  cyst  may  be  considerably  reduced 
without  performing  complete  cholecystectomy,  this  being 
effected  by  excising  the  redundant  portion,  ligaturing  the 
branches  of  the  cystic  artery,  and  inserting  a  drainage-tube, 
which  is  fixed  in  by  a  purse-string  suture,  the  edges  of  the 
portion  of  gall-bladder  remaining  being  fixed  to  the  aponeu- 
rosis of  the  abdominal  wall.     This  is  a  less  severe  operation 


3o4    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

than  complete  cholecystectomy,  and  if  the  ducts  are  clear  it 
answers  equally  well.     (Case  468.) 

After  cholecystectomy,  in  the  case  of  a  dilated  cystic  duct, 
where  the  ultimate  patency  of  the  common  duct  is  question- 
able, the  open  end  of  the  duct  may  be  connected  to  the 
bowel  by  choledochenterostomy,  as  in  Case  121. 

Unless  there  be  oozing,  or  unless  the  wound  has  been  in- 
fected by  pus  or  gall-bladder  secretion,  drainage  may  perhaps 
be  thought  unnecessary  ;  but  the  adage,  '  When  in  doubt, 
drain,'  is  a  good  one,  and  it  can  do  no  harm  to  leave  an 
efficient  drainage-tube  in  the  right  kidney  pouch  for  twenty- 
four  or  forty-eight  hours  after  extirpation  of  the  gall-bladder. 
Packing  with  iodoform  gauze  in  some  cases  is  better  than 
using  a  tube,  as  it  serves  the  double  purpose  of  arresting 
oozing  and  acting  as  a  drain. 

Statistics. — Martig  {Centralbl.  fur  Chir.,  April  14,  1894) 
collected  87  cases  of  cholecystectomy,  with  12  direct  and 
3  indirect  deaths,  thus  giving  a  mortality  of  17*24  per  cent. ; 
Kehr,  21  cases,  with  1  death,  giving  a  mortality  of  5  per  cent., 
but  in  his  later  statistics  the  mortality  in  sample  cases  is  only 
j*i  per  cent.  Mayo,  in  the  Report  of  the  Rochester  Hospital, 
Minnesota,  for  1902,  gives  31  cases  with  3  deaths,  a  mortality 
of  Q'6  per  cent.,  and  on  May  21,  1903,  he  reported  70  cases 
with  3  deaths,  a  mortality  of  4*3  per  cent. 

Terrier  (Chirurgie  du  foic  et  des  voies  biliave,  1901)  gives 
16  cases  collected  from  various  sources,  with  4  deaths. 

Delageniere  collected  38  cases  of  cholecystectomy,  with 
9  deaths,  thus  giving  a  mortality  of  23  per  cent. 

Courvoisier  collected  47  cases,  of  which  10  died  directly  as 
the  result  of  operation,  and  2  indirectly  from  the  operation, 
giving  a  mortality  of  25'5  per  cent. 

I  have  performed  the  operation  28  times,  with  4  deaths, 
giving  a  mortality  of  14*2  per  cent.,  this  including  both 
simple  and  malignant  cases,  but  in  the  absence  of  malignant 
disease  the  mortality  of  the  operation  has  been  6*2  per  cent. 

Cholecystectomy  has  hitherto  undoubtedly  been  a  more 
serious  operation  than  cholecystotomy,  but  since  the  method 
of  complete  exposure  of  the  operation  area  has  been  adopted, 
it  has  been  rendered  both  easier  and  safer. 


CHAPTER  XIII 

CHOLECYSTENTEROSTOMY 

Cholecystenterostomy  consists  in  establishing  an  artificial 
opening  between  the  gall-bladder  and  duodenum,  jejunum  or 
colon,  preferably  the  first,  when  it  may  be  termed  cholecyst- 
duodenostomy. 

Although  the  conception  of  the  operation  occurred  in- 
dependently to  Harley,  Gaston,  and  Nussbaum,  the  first 
operation  was  actually  performed  by  Winiwarter,  of  Liege, 
in  1880,  and  my  own  case,  in  1889,  was  the  first  operation 
performed  in  England,  and  was  the  first  cholecystenterostomy 
for  biliary  fistula. 

In  its  place  it  is  an  extremely  useful  operation,  but,  as  it  leaves 
the  cause  of  the  obstruction  unremedied,  it  ought  not  to  be  re- 
sorted to  in  obstruction  from  gall-stones  except  occasionally, 
where  a  more  radical  operation  is  impracticable  or  inadvisable. 

Dr.  Murphy,  of  Chicago,  in  a  paper  before  the  International 
Medical  Congress  at  Rome,  favoured  the  procedure  before 
other  methods,  and  gave  the  following  as  the  indications  for 
its  performance : 

1.  In  all  cases  where  it  is  desirable  to  drain  the  gall- 
bladder for  accumulations  therein. 

2.  In  all  cases  of  occlusion  of  the  ductus  choledochus. 

3.  In  all  cases  of  cholelithiasis  where  obstruction  of  the 
duct  is  present,  or  where  the  reflex  disturbances  of  digestion 
are  marked. 

4.  In  all  cases  of  cholecystitis,  either  with  or  without  gall- 
stones. 

5.  In  all  chronic  discharging  biliary  fistulse,  either  following 
operations  or  as  sequelae  of  pathological  changes. 

[  3°5  ]  20 


306    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

6.  In  all  cases  of  perforation  of  the  common  duct  when  it 
is  necessary  to  obliterate  the  duct  in  the  reparative  process. 

And  the  following  as  contra-indications  : 

i.  In  all  cases  in  which  the  gall-bladder  is  too  small  for 
the  insertion  of  the  button. 

2.  When  the  adhesions  are  so  extensive  that  the  bowel 
cannot  be  brought  in  contact  with  the  gall-bladder  without 
kinking. 

3.  In  obliteration  of  the  ductus  cysticus,  with  enormously 
enlarged  non-adherent  gall-bladder. 

In  these  cases  cholecystectomy  should  be  performed. 
Our  own  conclusions  are  that  the  operation  is  indicated — 

1.  In  biliary  fistulse  depending  on  stricture  in,  or  other 
permanent  occlusion  of,  the  common  duct. 

2.  Very  occasionally  in  cancer  of  the  head  of  the  pancreas, 
or  malignant  tumour  of  the  common  duct  leading  to  chronic 
jaundice  and  distended  gall-bladder,  for  in  such  cases  the 
mortality  will  necessarily  be  so  high  that  the  justifiability  of 
the  operation  is  questionable. 

3.  Very  occasionally  in  impaction  of  gall-stones  in  the 
ducts,  where  the  common  bile-duct  cannot  be  freely  exposed, 
and  the  patient  is  not  in  a  fit  condition  to  bear  the  more 
prolonged  operation  of  separating  adhesions,  and  crushing  or 
removing  the  concretion  by  choledochotomy. 

Contra-indications. — 1.  In  any  obstruction  of  the  bile-ducts 
which  can  be  cleared  away  with  reasonable  probability  of 
success. 

2.  In  malignant  disease  of  the  head  of  the  pancreas  or 
common  bile-duct  leading  to  distension  of  the  gall-bladder 
the  mortality  is  so  great  that  it  is  hardly  worth  incurring  the 
risk,  unless  the  patient  be  in  very  good  condition. 

3.  In  contracted  gall-bladder  where  it  is  impracticable  to 
insert  the  button  or  bobbin. 

4.  In  very  large  gall-bladder  with  obstruction  of  the  cystic 
duct,  where  cholecystectomy  should  be  done. 

The  operation  may  be  performed — 

(a)  By  means  of  simple  suture. 

(6)  By  means  of  the  decalcified  bone  bobbin. 

(c)   By  means  of  Murphy's  button. 


CHOLECYSTEXTEROSTOMY 


3°7 


The  operation  of  cholecystenterostomy  is  performed 
through  the  same  incision  as  is  made  for  cholecystotomy, 
and  after  the  gall-bladder  has  been  aspirated  and  the  in- 
testine clamped,  the  junction  is  effected.  If  sutures  be  em- 
ployed, a  semicircle  of  interrupted  silk  stitches  is  inserted  to 
unite  the  contiguous  serous  surfaces  of  the  gall-bladder  and 
gut ;  the  viscera  are  then  opened,  and  the  mucous  margins  of 
the  two  openings  are  united  by  interrupted  catgut  stitches, 


Fig.  69. — Diagram  to  show  Application  of  Mucous  or  Marginal 
Suture  in  the  Bone  Bobbin  Operation. 

after  which  the  circle  of  catgut  stitches  and  then  the  circle  of 
serous  sutures  is  completed. 

If  the  bone  bobbin  be  used,  two  continuous  sutures  only 
are  employed :  a  silk  stitch  to  unite  the  serous  surface 
I  or  J  inch  from  the  visceral  openings,  and  a  catgut  suture 
to  join  the  mucous  margins  of  the  visceral  openings. 

For  convenience,  the  posterior  semicircle  of  the  serous 
suture  is  first  applied,  and  the  needle  laid  aside  for  a  moment, 
but  not  unthreaded ;  the  openings  are  then  made,  and  the 
posterior  half  of  the  mucous  suture  is  inserted.     The  bobbin 

20 — 2 


3o8    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

is  then  introduced,  and  the  mucous  suture  continued  around 
until  it  meets  the  other  end  of  the  catgut,  when  the  two 
ends  are  tied  and  cut  off  short ;  the  serous  suture  is  then 
carried  around  the  anterior  half  until  it  reaches  the  point 
where  it  began,  when  the  two  ends  are  drawn  on  and  tied. 
(Figs  69  and  70.)  The  bobbin  keeps  open  the  lumen  until 
it  is  dissolved,  in  two  or  three  days,  and  the  mucous  and 
serous  sutures  effectually  protect  the  channel  from  leakage. 


Fig.  70. — Diagram  to  show  Application  of  Serous  Suture  in  the 
Bone  Bobbin  Operation. 

If  the  Murphy  button  be  used,  a  small  size  is  selected, 
and  two  running  sutures  are  applied,  as  shown  in  the 
diagram.  After  the  gall-bladder  has  been  emptied,  and  the 
bowel  clamped  either  by  intestinal  clamps  or  by  a  simple 
elastic  tourniquet,  the  openings  are  made  in  the  viscera  just 
sufficiently  large  to  admit  the  separate  ends  of  the  button. 
The  threads  are  then  drawn  on  and  tied  around  the  central 
barrel  of  the  button  (Figs.  71  and  72),  after  which  the  two 
ends  of  the  button  are  approximated  and  pushed  home  firmly. 
The  anastomosis  is  then  complete. 


CHOLECYSTENTEROSTOMY  309 

The  whole  process  occupies  a  very  short  time,  and  is  really 
very  simple.  It  is,  however,  necessary  to  bear  in  mind  that 
the  button  has  to  separate,  by  causing  the  approximated 
margins  of  the  openings  to  slough,  and  that  the  true  bond  of 
union  is  only  slight  at  first,   so  that  it   is  well  to  keep  the 


Fig.  71. — First  Stage  of  the  Button  Operation. 

patient  absolutely  quiet  for  at  least  a  fortnight,  lest  the  new 
bond  of  union  should  give  way  and  permit  of  extravasation 
of  the  visceral  contents.  In  malignant  cases,  where  union  is 
often  delayed,  there  is  always  a  feeling  of  uncertainty  attend- 
ing the  employment  of  the  Murphy  button  until  a  full  fort- 
night has  elapsed.  In  considering  the  question  of  cholecyst- 
enterostomy,  it  has  to  be  borne  in  mind  that  the  operation 


310    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

can  only  be  done  when  the  gall-bladder  is  of  moderate  size, 
or  dilated,  and  that  it  is  inapplicable  to  the  difficult  class  of 
cases  where  a  gall-stone  is  in  the  common  duct  and  the  gall- 
bladder is  atrophied.  When  it  can  be  done,  the  anastomosis 
should  be  made  to  the  duodenum,  but  if  preferred,  a  free  loop 
of  jejunum  may  be  selected  and  brought  over  the  hepatic 
flexure  of  the  colon.     In  some  cases  where  we  have  made  the 


Fig.  72. —  Last  Stages  of  the  Button  Operation. 

anastomosis  between  the  gall-bladder  and  the  colon,  the 
result  has  been  quite  as  satisfactory  as  if  the  gall-bladder  and 
duodenum  had  been  joined  ;  and  as  the  operation  of  joining 
the  gall-bladder  and  colon  is  so  much  simpler  than  that  of 
joining  the  gall-bladder  to  the  duodenum,  and  in  cases  of 
biliary  fistula  may  often  be  done  without  actually  opening  the 
peritoneum,  we  are  inclined  to  favour  the  colic  anastomosis. 


CHOLECYSTENTEROSTOMY  311 

The  following  is  a  description  of  a  case  of  gall-bladder 
colon  operation. 

Case  13. — Cholccystotomy — Biliary  Fistula — Stricture  of 
Common  Duct — Cholecystenterostomy — Recovery. — On  January 
9,  1888,  a  married  woman,  aged  forty-two,  was  admitted  to 
the  Leeds  General  Infirmary,  suffering  from  acute  local 
peritonitis,  with  a  tumour  in  the  region  of  the  gall-bladder. 

On  January  14  laparotomy  was  performed  through  the 
upper  part  of  the  right  linea  semilunaris,  and  8  ounces  of 
fetid  pus  removed  from  the  gall-bladder.  Exploration  of  the 
ducts  by  the  finger  and  a  probe  failed  to  discover  any  gall- 
stones. The  gall-bladder  was  stitched  to  the  abdominal 
wound  and  drained,  and  the  patient  made  a  good  recovery, 
but  with  a  biliary  fistula.  Although  she  had  retained  good 
health  during  the  fifteen  months  when  the  fistula  was  open 
and  discharging  the  whole  of  the  bile,  her  condition  was  a 
very  miserable  one,  since  no  apparatus  could  be  made  to 
catch  the  overflowing  fluid  when  she  was  walking  about,  and 
her  dressings  and  clothes  became  saturated. 

Cholecystenterostomy  was  performed  on  March  2, 1889,  by 
reopening  the  abdomen  through  the  old  cicatrix  in  the  right 
linea  semilunaris.  The  viscera  in  the  neighbourhood  were 
found  to  be  so  matted  together  that  it  seemed  to  be  impos- 
sible to  fix  the  gall-bladder  to  the  duodenum ;  and  as  the 
hepatic  flexure  of  the  colon  was  conveniently  near,  the 
gall-bladder  was  fixed  to  it  by  a  double  row  of  sutures  round 
a  decalcified  bone  bobbin,  a  free  communication  being  made 
between  the  two  viscera.  After  a  tardy  convalescence,  she 
completely  recovered,  and  was  well  in  every  respect  ten 
years  later. 

Cholecystenterostomy  has  been  advocated  by  some  surgeons 
for  obstruction  in  the  common  duct  by  gall-stones,  the  gall- 
bladder being  connected  to  the  duodenum  or  colon.  In  my 
earlier  practice  I  performed  this  operation,  but  since  adopting 
the  easy  and  effectual  method  of  exposing  the  whole  length  of 
the  bile-ducts  I  have  practically  discarded  cholecystenteros- 
tomy, for  it  leaves  the  cause  untouched,  and  should  the 
artificial  opening  close,  the  symptoms  inevitably  return,  as 
in  the  following  case  : 


312    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Case  287.  —  Chronic  Pancreatitis  with  Gall-stone  in  the 
Common  Bile-duct  —  Cholecystenterostomy  —  Relief — Relapse. — 
A  man,  aged  forty-five,  from  Queensbury,  was  admitted  into 
the  Leeds  General  Infirmary,  under  my  care,  on  November  3, 
1899,  suffering  from  jaundice,  with  repeated  attacks  of 
pain  and  ague-like  seizures.  He  had  been  well  up  to  thirteen 
months  before  his  admission,  when  the  attacks  began,  and 
since  their  onset  he  had  lost  6  stones  in  weight.  Jaundice 
followed  the  first  seizure  and  persisted,  but  after  each  attack 
of  pain  it  was  more  intense.  He  was  so  weak  and  ill  that 
it  was  feared  he  could  not  bear  operation.  An  enlargement 
of  the  right  lobe  of  the  liver  could  be  felt,  and  on  its  inner 
side  in  the  mid-line  just  above  the  umbilicus  there  was 
another  tumour  situated  behind  the  stomach.  On  Novem- 
ber 9,  an  operation  was  performed  on  a  heated  table  with  the 
patient  enveloped  in  wool,  an  injection  of  10  minims  of  solu- 
tion of  strychnia  having  been  previously  given.  On  opening 
the  abdomen  an  enlargement  of  the  right  lobe  of  the  liver 
was  seen,  the  gall-bladder  was  found  shrunken  under  adhesions, 
a  floating  gall-stone  too  hard  to  crush  was  felt  in  the  common 
duct,  and  a  hard  nodular  tumour  of  the  head  of  the  pancreas 
was  discovered.  As  the  latter  was  thought  to  be  malignant, 
and  the  patient  was  extremely  feeble,  choledochotomy  was 
not  performed,  but  the  gall-bladder  was  connected  to  the 
duodenum  by  a  Murphy's  button,  in  order  to  give  temporary 
relief  to  the  jaundice,  fever,  and  pain.  He  had  a  severe 
rigor  on  the  night  of  operation,  but  afterwards  progressed 
satisfactorily  and  recovered  from  the  operation.  The  button 
passed  on  the  twelfth  day,  and  as  he  had  gained  some  weight 
and  was  taking  his  food  well,  it  was  thought  that  the  opera- 
tion was  going  to  be  of  real  benefit  to  him.  The  subsequent 
history  of  the  case  was  as  follows  : 

On  December  8  (a  month  and  a  day  after  operation)  he 
had  a  feeling  of  chilliness,  and  a  temperature  of  1010  F. 
followed  for  two  days,  his  temperature  being  afterwards 
normal  for  twelve  days,  when  he  had  a  rigor  and  a  return  of 
the  jaundice  ;  from  this  time,  although  he  got  up  every  day, 
he  gradually  became  weaker,  and  in  January,  1900,  he 
developed  bronchitis,  which  ushered  in  the  final  scene.     At 


CHOLECYSTENTEROSTOMY  31 


j'  j 


the  post-mortem  examination  the  peritoneum  was  found  to 
be  free  from  inflammation,  and  the  gall-bladder  was  found  to 
be  connected  to  the  duodenum  i£  inches  beyond  the  pylorus, 
but  the  opening  had  contracted  so  that  it  would  only  admit 
a  fine  probe.  The  common  bile-duct  was  dilated  and 
ulcerated,  and  it  contained  a  gall-stone  the  size  of  a  filbert. 
The  liver  was  considerably  enlarged,  and  the  right  lobe  was 
occupied  by  an  abscess  containing  thick,  slimy  muco-pus. 
The  walls  of  the  abscess  cavity  were  ragged  and  ill-defined, 
and  it  reached  nearly  to  the  surface  both  in  front  and  behind. 
It  was  doubtless  the  result  of  the  suppurative  cholangitis 
which  was  present.  The  pancreas  was  much  indurated 
about  the  head,  and,  together  with  the  indurated  tissues  in 
the  small  omentum,  gave  on  palpation  the  sensation  of  a 
tumour.  On  section  it  presented  to  the  naked  eye  the 
appearance  of  chronic  inflammation  rather  than  growth,  and 
on  microscopical  examination  this  view  was  confirmed,  there 
being  a  great  excess  of  interstitial  fibrous  tissue,  but  no  sign 
of  cancer. 

The  statistics,  according  to  Murphy,  given  in  the  Transac- 
tions of  the  International  Congress  at  Rome,  were : 
23  cases  by  suture,  with  8  deaths  =  34  per  cent. 
21  cases  for  gall-stone  by  button,  no  deaths. 
2  cases  for  malignant  disease,  with  2  deaths  =  100  per 
cent. 

From  a  report  up  to  1897,  which  Dr.  Murphy  was  so 
kind  as  to  furnish,  cholecyst-duodenostomy  had  been  per- 
formed with  the  aid  of  the  anastomosis  button  in  67  non- 
malignant  cases,  with  only  3  deaths,  these  being  due  to  con- 
tinuous haemorrhage  from  laceration  of  the  liver  substance 
on  the  seventh  day,  to  cholaemia  on  the  fourth  day,  and  to 
septicaemia  on  the  fourth  day,  respectively.  Of  his  12  malig- 
nant cases  10  died,  giving  a  mortality  of  83*3  per  cent. 

My  own  cases  are  25  in  number,  with  6  deaths.  Of  these, 
17  were  done,  for  gall-stones,  chronic  pancreatitis,  or  fistula, 
and  all  recovered  ;  7  for  malignant  disease,  with  5  deaths  ;  and 
1  for  suppurative  cholangitis,  in  which  case  the  patient  died. 

W.  H.  Mayo  reports  5  cases  for  chronic  pancreatitis,  all  of 
which  recovered,  and  4  for  cancer,  with  1  death. 


314    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Choledochostomy. 

Choledochostomy  is  the  term  applied  to  the  direct  surface 
drainage  of  a  dilated  bile-duct,  an  operation  which  I  fre- 
quently perform  as  part  of  the  technique  of  choledochotomy, 
and  which  is  very  successful ;  but  there  is  a  class  of  cases 
where  the  common  duct  attains  a  very  large  size  (see  p.  195), 
which  probably  also  indicates  corresponding  changes  in  the 
ducts  within  the  liver,  and  the  treatment  of  which  is  not  very 
satisfactory.  Terrier  has  described  four  cases  {Revue  de 
Chintrgie,  February,  1893)  ;  Dr.  Arnison,  of  Newcastle,  had 
a  fifth  under  his  care,  and  a  specimen  from  a  sixth  will  be 
found  in  Guy's  Museum,  all  ending  fatally  within  a  few  days 
or  weeks  of  operation,  owing  to  associated  choledochitis  and 
infection  of  the  bile  channels  in  the  liver  itself. 

The  following  cases  which  recovered  are  therefore  of 
interest  as  showing  that  the  operation  is  not  of  necessity 
fatal. 

In  July,  1896,  I  performed  choledochostomy  on  a  man  of 
twenty-five,  after  crushing  and  removing  a  gall-stone  the  size 
of  a  hen's  egg,  situated  at  the  junction  of  the  cystic  and 
common  ducts.  The  gall-bladder  being  much  smaller  than 
the  duct,  it  was  found  easier  to  fix  and  drain  the  latter.  The 
patient  made  a  good  recovery  (Case  150).  I  have,  since 
the  above,  had  other  successful  cases  of  drainage  of  the 
dilated  common  duct ;  Case  511  is  an  example. 

Choledochenterostomy. — Where  it  is  impossible  to  clear  the 
ducts,  instead  of  performing  choledochostomy,  the  operation 
of  choledochenterostomy  may  be  done,  the  union  of  the  dilated 
duct  to  the  duodenum  being  made  by  means  of  a  decalcified 
bone  bobbin  or  a  Murphy's  button.  Case  526,  reported  in 
the  Appendix  is  a  good  example,  and  the  operation  has  also 
been  done  successfully  by  Drs.  Sprengel  and  Riedel,  and  by 
Dr.  Swaine. 

In  some  cases,  the  shrunken  and  diseased  gall-bladder  can 
be  removed,  and  the  end  of  the  dilated  cystic  duct  fixed  to 
the  bowel  by  a  Murphy's  button  (as  in  Case  121),  or  by  a  bone 
bobbin  (as  in  Cases  55  and  226).  It  will  not  usually  be 
necessary  to  employ  drainage.  In  Case  250  laceration  of 
the  liver  occurred  in  separating  adhesions,  and  although  the 


CHOLEDOCHENTEROSTOUY  315 

laceration  was  sutured,  haemorrhage  occurred  into  the 
peritoneum,  with  extravasation  of  septic  bile,  though  no 
laceration  of  the  ducts  could  be  found,  and  the  new  artificial 
opening  appeared  to  be  perfectly  sound. 

The  following  case  is  an  example  of  cysto-dochenterostomy : 

Case  121. — Mucous  Fistula — Cholecystectomy — Cholcdochenter- 
ostomy — Recovery. — Mr.  P.,  aged  fifty-five,  seen  at  the  Leeds 
Infirmary,  July  24,  1895.  Operation  undertaken  for  closing  a 
mucous  fistula,  when  the  gall-bladder  was  found  to  be  forming 
a  tumour  with  walls  h,  to  J  inch  thick.  Cholecystectomy 
was  performed,  and  the  open  end  of  the  cystic  duct  con- 
nected to  the  small  bowel  by  means  of  a  Murphy's  button. 
A  smooth  recovery  followed,  and  when  heard  of  in  1896  he 
was  completely  cured  and  in  good  health. 

Case  511. — Dilated  Common  Duct — Chronic  Pancreatitis — 
Cholecystotomy — Choledochostomy. — Miss  F.,  aged  twenty-eight, 
seen  with  Dr.  Griffiths,  Swansea.  Four  years  previously  she 
had  typhoid  fever,  and  had  never  been  well  since;  a  year 
previously  she  had  an  attack  of  pain  followed  by  jaundice 
and  some  enlargement  of  the  gall-bladder.  She  was  operated 
on  by  Dr.  Griffiths  in  June,  1902  ;  no  gall-stones  were  found, 
but  the  head  of  the  pancreas  was  much  enlarged.  The 
gall-bladder  was  drained,  and  the  wound  healed  within  the 
month.  The  patient  was  well  up  to  March,  1903,  when  she 
had  a  recurrence  of  the  jaundice,  with  sickness,  retching,  and 
pain  ;  she  became  very  ill,  and  lost  flesh  rapidly.  When  we 
saw  her  together  there  was  some  enlargement  of  the  gall- 
bladder, and  a  distinct  cystic  swelling  over  the  pancreas. 
Pancreatic  crystals  found  in  urine. 

Operation,  June  4,  1903. — Inflamed  and  distended  gall- 
bladder ;  large  cyst  on  the  inner  side  of  the  gall-bladder 
containing  bile  and  pus — probably  a  dilated  common  bile- 
duct  ;  finger  passed  into  the  cyst  reached  behind  the 
stomach  and  duodenum  ;  drainage  of  the  gall-bladder  and 
of  the  cyst. 

After-History. — Patient  made  a  good  recovery  from  the 
operation  and  returned  home,  but  it  was  not  considered 
wise  to  leave  out  the  tubes,  and  subsequently  a  further  opera- 
tion was  necessary  (Case  526). 


3i6    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Case  526. — Chronic  Pancreatitis — Dilated  Common  Bile- 
duct  —  Cholecystitis  —  Cholecystectomy  —  Choledochenterostomy . — 
Miss  F.,  aged  twenty-eight,  seen  with  Dr.  Griffiths,  Swan- 
sea. Since  the  former  operation  there  had  continued  to 
drain  away  from  the  tube  into  the  dilated  common  bile-duct 
20  to  30  ounces  of  bile.  No  bile  entered  the  bowel,  and 
from  the  tube  leading  into  the  gall-bladder  from  4  to 
6  ounces  of  clear  mucus  drained  away  each  day.  The 
patient  was  thin  and  feeble,  had  no  appetite  for  food,  and 
was  unable  to  digest  anything  beyond  a  little  milk.  An 
examination  of  the  urine  showed  the  absence  of  albumin 
and  sugar,  but  the  presence  of  pancreatic  crystals,  which 
dissolved  in  from  three-quarters  to  one  minute.  The  faeces 
contained  fat  and  muscle  fibre.  An  examination  of  the 
bile  by  Dr.  Eastes  was  reported  to  contain  numerous 
bacilli,  which  proved  to  be  the  Bacillus  enteritidis  of 
Gartner. 

Operation,  October  8,  1903. — Head  of  pancreas  found  to  be 
enlarged,  but  no  concretion  was  felt  in  it  or  in  the  common 
bile-duct.  Gall-bladder  completely  excised,  the  cystic  duct 
being  ligatured  ;  the  dilated  common  bile-duct  was  then 
connected  to  the  duodenum  by  means  of  a  decalcified  bone 
bobbin,  and  the  wound  was  closed.  The  same  evening  the 
patient  expressed  herself  as  feeling  hungry  for  the  first  time 
since  her  illness,  this  apparently  being  dependent  on  the  bile 
and  pancreatic  fluid  entering  the  intestine.  She  straightway 
began  to  absorb  whatever  nourishment  was  taken,  had  her 
bowels  moved  on  the  second  day,  gained  strength,  resumed 
her  natural  colour,  and  made  such  a  rapid  convalescence  that 
she  returned  home  within  the  month,  having  gained  7  pounds 
in  weight  since  the  operation. 


DECALCIFIED  BONE  BOBBINS,  AS  MADE  FOR  THE  AUTHOR  BY 

MESSRS.  DOWN  BROS. 


No.   i. 


No.   2. 


No.  3. 


No.  4. 


No.  5. 


No.  6. 


No.  10. 


No.   11. 


Fig.  73. 


No.  1  is  the  size  that  may  be  employed  for  repairing  the  bile-ducts. 

Nos.  2,  3,  and  4  are  the  sizes  used  for  Cholecystenterostomy  and  Choledochenterostomy 

Nos.  5,  6,  7,  and  8  are  employed  in  Gastroenterostomy  and  Enterostomy. 

Nos.  9  and  10  in  Colectomy,  and  No.  11  in  Pyloroplasty. 


APPENDIX 


APPENDIX 


LIST  OF  CASES. 

Gall-stones  :  Cholecystotomy. 

Case  i. — Mrs'.  F.,  aged  thirty-three,  seen  with  Mr.  "Wheel- 
house. 

Operation. — 21/6/1884.  Cholecystotomy;  distended  gall-bladder  ; 
twelve  gall-stones  removed. 

Aftev-Histovy. — Patient  made  a  good  recovery.  Small  mucous 
fistula.     In  good  health,  1902. 

Gall-stones  :  Cholecystotomy ;  Subsequent  Cholecystectomy. 

Case  2. — Miss  L.,  aged  twenty-two,  seen  with  Dr.  Churton. 

Opevation. — 20/7/1885.  Cholecystotomy;  distended  gall-bladder; 
sixty  gall-stones  removed. 

Aftev-Histovy. — Recovery.  Mucous  fistula  for  a  time,  cured  by 
cholecystectomy.     In  good  health,  1895. 

Gall-stones,  Jaundice  :  Cholecystotomy  ;  Subsequent  Cholecystentev- 

ostomy. 

Case  3. — Mrs.  B.,  aged  forty -two,  seen  with  Dr.  Loe.  Gall- 
stones, jaundice  present. 

Opevation. — 14/1/1888.  Cholecystotomy  ;  empyema  of  gall- 
bladder. 

Aftev-Histovy. — Recovery.  Biliary  fistula,  cured  by  cholecyst- 
enterostomy.     Ultimately  quite  well  and  in  good  health,  1898. 

Gall-stones  :  Cholecystotomy. 

Case  4. — Mrs.  C,  aged  forty-four,  seen  at  infirmary. 
Opevation. — 19/3/1888.     Cholecystotomy;    fourteen   gall-stones 
removed. 

Aftev-Histovy. — Good  recovery. 

[  321  ]  21 


322    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones  :  Cholecystotomy. 

Case  5. — H.  F.,  female,  aged  thirty-two,  seen  at  infirmary. 
Operation. — 2/5/1888.     Cholecystotomy  ;    forty-two   gall-stones 
removed. 

After-History. — Good  recovery. 

Gall-stones,    Empyema   of  Gall-bladder,    Abscess   of   Liver,    Infective 
Cholangitis  :  Cholecystotomy. 

Case  6. — G.  T.,  female,  aged  forty,  seen  with  Dr.  Churton. 
Infective  cholangitis,  jaundice. 

Operation. — 14/6/1888.  Cholecystotomy  ;  two  large  gall-stones 
removed  ;  empyema  of  gall-bladder  and  abscess  of  liver. 

After-History. — Recovery.     Mucous  fistula  ;  otherwise  well. 

Gall-stones  :  Cholecystotomy  ;  Cholelithotnty. 

Case  7.  — S.  T.,  female,  aged  thirty-one,  seen  at  infirmary. 
Tumour  of  gall-bladder,  two  years. 

Operation. — 1 5/6/1 888.  Cholecystotomy  and  cholelithotrity  ; 
one  large  gall-stone  removed  from  gall-bladder,  one  crushed  in 
cystic  duct. 

After-History. — Good  recovery. 

Gall-stones :  Cholecystotomy. 

Case  8. — E.  J.,  female,  aged  forty,  seen  at  infirmary. 
Operation. — 9/7/1888.     Cholecystotomy;  distended  gall-bladder; 
two  large  gall-stones  removed. 

After -History. — Complete  recovery. 

Gall-stones,  Jaundice :  Cholecystotomy. 

Case  9. — A.  H.,  female,  aged  forty-two,  seen  with  Dr.  A.  Atkin- 
son.    Slight  jaundice. 

Operation. — 29/7/1888.  Cholecystotomy  ;  two  large  gall-stones 
removed,  one  from  gall-bladder,  and  one  from  the  junction  of 
cystic  and  common  duct. 

After-History. — Complete  recovery  ;  well  three  years  after. 

Gall-stones :  Cholecystotomy  ;  Subsequent  Cholecystectomy. 

Case  10. — S.  G.,  female,  aged  forty-nine,  seen  with  Dr.  Fletcher 
Home,  Barnsley. 

Operation. — 29/8/1888.  Cholecystotomy  ;  sixty-six  gall-stones 
removed. 

After-History. — Complete  recovery  for  a  time,  but  ultimately 
developed  stricture  of  the  cystic  duct,  and  required  cholecystec- 
tomy.    (See  Case  22.) 


APPENDIX  323 

Cancer  of  Pancreas :  Cholecystotomy ,  Hemorrhage. 

Case  11.— Mr.  G.  B.,  aged  fifty,  seen  with  Dr.  Clifford  Allbutt. 
Tumour  formed  by  distended  gall-bladder  ;  intense  jaundice  ; 
cancer  of  pancreas. 

Operation. — 10/9/1888.     Cholecystotomy. 

After-History. — Death  ninth  day  from  haemorrhage  and  exhaus- 
tion. 

Cancev  of  Common  Bile-duct,  Suppurative  Cholangitis  : 
Cholecystotomy. 

Case  12. — Mr.  W.  T.,  aged  forty-two,  seen  with  Dr.  Churton. 
Deep  jaundice  and  suppurative  cholangitis ;  distended  gall-bladder ; 
cancer  of  common  bile-duct. 

Operation. — 23/12/1888.     Cholecystotomy. 

Ajter-History. — Relief  for  a  time,  but  death  later  from  progress 
of  disease. 

Biliary  Fistula,  Stricture  of  Common  Bile-duct :  Cholecystenterostomy. 

Case  13. — Mrs.  B.,  aged  forty-four,  seen  at  infirmary.  (Sequel 
of  Case  3.) 

Operation. — 2/3/1889.  Stricture  of  common  bile-duct ;  cholecyst- 
enterostomy; gall-bladder  united  to  colon  by  sutures.    (See  p.  117.) 

After -History. — Good  recovery  ;  quite  well  in  1898. 

Gall-stones  :  Cholecystotomy. 

Case  14. — Mr.  C,  aged  forty-one,  seen  at  infirmary.  Distended 
gall-bladder. 

Operation. — 28/3/1889.  Cholecystotomy  ;  fourteen  gall-stones 
removed. 

After-History . — Complete  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  15. — Mrs.  H.,  aged  thirty-two,  seen  with  Dr.  Clifford 
Allbutt  and  Mr.  Wheelhouse.     Distended  gall-bladder. 

Operation. — 2/5/1889.  Cholecystotomy;  forty-two  gall-stones 
removed. 

After-History. — Good  recovery. 

Gall-stones,  Jaundice  :  Cholecystotomy  ;  Cholelithotrity . 

Case  16. — Mr.  H.,  aged  fifty-five,  seen  with  Dr.  Gordon  Black, 
Harrogate.     Jaundice. 

Operation. — 7/9/1889.  Cholecystotomy;  seventy  gall-stones 
removed,  others  crushed  in  common  duct. 

After -History. — Complete  recovery  ;  quite  well,  1903. 

21 — 2 


324    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones  :  Cholecystotomy. 

Case  17. — A.  W.,  female,  aged  forty-one,  seen  with  Dr.  Swann, 
Batley. 

Operation. — 26/9/1889.     Cholecystotomy  ;  three   gall-stones   re- 
moved. 
Aftev-Histovy. — Good  recovery  ;  when  last  heard  of  quite  well. 

Jaundice,  Gall-stones  :  Cholecystotomy. 

Case  18. — Mrs.  F.,  aged  thirty-four,  seen  with  Dr.  G.  Coleman. 
Jaundice  present. 

Operation. — 10/10/1889.  Cholecystotomy  ;  twelve  gall-stones 
removed  ;   shrunken  gall-bladder. 

Aftev-Histovy. — Good  recovery ;  quite  well  for  a  time,  then  had 
recurrence  of  symptoms  from  gall-stones  left  in  common  bile-duct. 
(See  Case  37.) 

Gall-stones  :  Cholecystotomy. 

Case  19. — Mrs.  H.,  aged  thirty-two,  seen  with  Dr.  Fairbank, 
Doncaster.     Distended  gall-bladder. 

Operation. — 16/1/1890.  Cholecystotomy  ;  two  gall-stones  re- 
moved. 

Aftev-Histovy. — Good  recovery  ;  quite  well  when  last  seen. 

Gall-stones  :  Cholecystotomy. 

Case  20. — G.  T.,  female,  aged  forty-two,  seen  at  infirmary. 
Opevation. — 14/2/ 1890.     Cholecystotomy  ;    one  large  gall-stone 
removed. 

Aftev-Histovy. — Good  recovery ;  quite  well  when  last  seen. 

Gall-stones  :  Cholecystotomy. 

Case  21. — Mr.  R.,  aged  fifty,  seen  with  Dr.  Britton,  Harro- 
gate. 

Opevation. — 5/5/1890.  Cholecystotomy;  one  large  gall-stone 
removed. 

Aftcv-llistovy. — Complete  recovery;  well  when  seen  in  1897. 

Stvictuve  of  Cystic  Duct,  Mucous  Fistula  :  Cholecystectomy. 

Case  22. — Mrs.  G.,  aged  fifty-one,  seen  with  Dr.  Fletcher 
Home,  Barnsley.  Mucous  fistula ;  stricture  of  cystic  duct, 
following  gall-stones.     (See  Case  10.) 

Opevation. — 14/5/ 1890.     Cholecystectomy. 

Aftcv-llistovy. — Complete  and  permanent  cure  ;  well,  1893. 


APPENDIX  325 

Gall-stones  in  Common  Duct :  Cholelithotvity  and  Cholecystotomy. 

Case  23. — Mrs.  C,  aged  thirty,  seen  with  Dr.  Dobson.  Jaun- 
dice present. 

Operation. — 3/6/1890.  Cholecystotomy  and  cholelithotrity  ; 
several  stones  crushed  in  common  duct.  After  seven  weeks  the 
common  duct  was  cleared  by  injecting  a  solution  of  turpentine  in 
ether. 

After-History. — Cure;  quite  well  1900. 

Gall-stones  :  Cholecystotomy. 

Case  24. — Mr.  B.,  aged  twenty-nine,  seen  with  Dr.  Dearden- 
Wyke. 

Operation. — 1 9/6/1 890.  Cholecystotomy  ;  six  gall-stones  re- 
moved ;  shrunken  gall-bladder. 

After-History. — Good  recovery  ;  quite  well,  1892. 

Chronic  Pancreatitis  :  Exploratory  Operation  ;   Separation  of  Adhesions. 

Case  25. — Mrs.  B.,  aged  forty- two,  seen  with  Dr.  Sykes,  Cleck- 
heaton.  Deep  jaundice  present  ;  tumour  close  to  common  duct, 
thought  to  be  malignant  ;  extensive  adhesions  separated. 

Operation. — 22/6/1890.     Exploratory. 

After-History. — Good  recovery ;  perfectly  well  some  months 
after.  In  the  light  of  recent  knowledge,  I  suspect  this  was  a  case 
of  chronic  pancreatitis. 

Gall-stones :  Cholecystotomy  and  Cholelithotrity. 

Case  26. — Mrs.  P.,  aged  twenty-nine,  seen  at  infirmary. 
Spasms  for  years. 

Operation. — 1 5/8/1 890.  Cholelithotrity  and  cholecystotomy; 
shrunken  gall-bladder,  with  numerous  adhesions;  gall-stone 
crushed  in  cystic  duct. 

After-History. — Good  recovery. 

Gall-stones,  Jaundice,  Empyema  of  Gall-bladder,  Abscess  of  Liver  : 

Cholecystotomy. 

Case  27. — J.  E.,  female,  aged  twenty-five,  seen  at  infirmary. 
Jaundice  present. 

Operation. — 2/9/1890.  Cholecystotomy  ;  gall-stones  in  gall- 
bladder, with  empyema  ;  also  abscess  of  liver,  containing  gall- 
stones (thirty-eight  in  all). 

After-History. — Good  recovery. 

Spasms  :  Adhesions  around  Gall-bladder  separated,  Gastrolysis. 
Case  28. — Mr.  C,  aged  twenty-two,  seen  at  infirmary.     Five 
years'  history  of  spasmodic  pains  in  gall-bladder  region. 

Operation. — 30/10/1890.     Exploratory;  adhesions  separated. 
After-History. — Good  recovery  ;  quite  well  some  months  later. 


326    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones   in  Common  Duct,  Jaundice,  Infective  Cholangitis :  Chole- 
lithotrity and  Choice ystotomy. 

Case  29. — Mrs.  H.,  aged  thirty,  seen  with  Dr.  Squance,  Sunder- 
land. Jaundice  present ;  infective  cholangitis  ;  persistent  vomit- 
ing ;  loss  of  flesh. 

Operation. — 1/11/1890.  Cholecystotomy  and  cholelithotrity;  one 
gall-stone  removed,  several  crushed  in  ducts. 

After-History. — Good  recovery  ;  quite  well  some  months  later. 

Volvulus  causing  Obstruction,  Large  Gall-stone  :  Laparotomy. 

Case  30. — Mrs.  E.,  aged  sixty-eight,  seen  with  Dr.  Hamilton, 
Crowle.  Gall-stone  producing  intestinal  colic  and  obstruction, 
with  volvulus  of  small  bowel. 

Operation.  — 12/11/1890.  Laparotomy  and  untwisting  volvulus  ; 
large  gall-stone  i-|  inches  by  1  inch  afterwards  passed  per  anum. 

After-History. — Complete  recovery  ;  when  heard  of  a  year  later 
was  quite  well. 

Gall-stone  in  Common  Duct,  Jaundice,  Infective  Cholangitis  :    Chole- 
lithotrity and  Cholecystotomy. 

Case  31. — Mrs.  W.,aged  forty,  seen  with  Dr.  Purdy,  Woodles- 
ford.     Jaundice  present,  and  infective  cholangitis. 

Operation. — 14/11/1890.  Cholelithotrity  and  cholecystotomy; 
large  gall-stone  crushed  in  common  duct. 

After-History. — Rapid  recovery;  well  in  1891. 

Gall-stones  :  Cholecystotomy  and  Cholelithotrity. 

Case  32. — Mr.  R.,  Newhaven,  Connecticut,  aged  thirty-nine, 
seen  with  Mr.  Wheelhouse. 

Operation. — 29/12/1890.  Cholecystotomy  and  cholelithotrity; 
numerous  gall-stones  removed. 

After-History. — Rapid  recovery.  Returned  to  America  within 
the  month.     Well  in  1893. 

Cancer  of  Pancreas,  Hemorrhage,  Deep  Jaundice  :  Cholecystotomy. 

Case  33. — Mrs.  R.,  aged  forty-five,  seen  with  Dr.  Hollings, 
Calverley.  Cancer  of  pancreas  with  gall-stones;  intense  jaundice; 
haemorrhage  from  nose,  bowel,  etc. 

Operation. — 29/12/1890.     Cholecystotomy. 

After-History. — Death  next  day.  Patient  extremely  exhausted 
at  the  time  of  operation,  which  probably  did  not  much  shorten 
life. 


APPENDIX  327 

Gall-stones  :  C  hole  cystotomy  ;  Cholelithotrity. 

Case  34. — Mrs.  W.,  aged  fifty-five,  seen  at  infirmary.  Slight 
jaundice. 

Operation.  — 13/1/1891.  Cholecystotomy  and  cholelithotrity; 
gall-stones  crushed  in  cystic  duct. 

After-History. — Cured. 

Gall-stone  and  Cystic  Dilatation  of  Hepatic  Duct  in  Liver  :  Removal  of 

Gall-stones  and  Drainage. 

Case  35. — Mrs.  C,  aged  forty-two,  seen  with  Dr.  Lee,  Dews- 
bury.     Jaundice  present. 

Operation.  —  5/2/1891.  Hepatochotomy  and  cholecystotomy. 
Cyst  of  liver  due  to  dilated  hepatic  duct.  Incision  of  duct  in 
liver,  about  8  ounces  of  fluid  evacuated,  and  drainage  adopted  ; 
free  bleeding  controlled  by  gauze  packing ;  three  gall-stones 
removed. 

After-History. — Recovery.  Small  discharge  of  bile  persisted 
for  a  time. 

Chronic  Pancreatitis  :  Exploration  ;  Aspiration  of  Gall-bladder. 

Case  36. — Mr.  G.,  aged  fifty,  seen  with  Dr. ,  Chatham. 

Tumour  of  head  of  pancreas ;  deep  jaundice ;  distended  gall- 
bladder. 

Operation. — 17/2/1891.  Exploratory;  30  ounces  of  fluid  removed 
by  aspirator.  Swelling  of  head  of  pancreas,  thought  to  be  cancer, 
but  possibly  chronic  pancreatitis. 

After-History. — Marked  relief  for  a  time.  Returned  home 
within  the  month. 

Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 

Cholelithotrity. 

Case  37. — Mrs.  F.,  aged  thirty-five,  seen  with  Dr.  Coleman, 
Hemsworth.     Jaundice  present. 

Operation. — 26/2/1891.  Cholecystotomy  and  cholelithotrity; 
stones  crushed  in  common  duct. 

After-History. — Good  recovery  from  operation  and  well  for  some 
time,  but  in  1896  had  recurrence,  due  probably  to  fragments  left. 
(See  Case  539.) 

Gall-stone  in  Common  Duct :  Cholelithotrity  ;  Cholecystotomy. 

Case  38. — Mr.  L.,  aged  forty -five,  seen  with  Dr.  Drake, 
Headingley.     Deep  jaundice. 

Operation. — 5/3/1891.  Cholecystotomy  and  cholelithotrity; 
gall-stone  crushed  in  common  duct. 


328    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

After-History. — Recovery  from  operation,  but  a  month  later  had 
diarrhoea,  and  died  rather  suddenly.  Nothing  abnormal  found  in 
region  of  bile-ducts  ;  wound  had  healed. 

Gall-stone  in  Common  Duct,  Jaundice :  Cholecystotomy ; 
Cholelithotrity. 

Case  39. — Mrs.  S.,  aged  thirty-five,  seen  with  Dr.  Oglesby, 
York.     Jaundice. 

Operation. — 12/3/1891.  Cholecystotomy  and  cholelithotrity  ; 
stones  crushed  in  common  duct. 

After-History. — Good  recovery  ;  well,  1896. 

Gall-stone,  Jaundice  :  Cholecystotomy. 

Case  40. — Mrs.  H.  M.  C,  aged  forty-two,  seen  at  infirmary. 
Intense  jaundice  present. 

Operation. — 19/3/1891.  Cholecystotomy;  one  gall-stone  re- 
moved J  inch  in  diameter. 

After-History. — Recovery.  After  returning  home  at  the  month- 
end  contracted  influenza,  and  had  fatal  pneumonia. 

Gall-stones  :  Cholecystotomy  ;  Cholelithotrity. 

Case  41. — Mrs.  H.,  aged  thirty-two,  seen  with  Dr.  Braith- 
waite. 

Operation. — 23/3/1891.  Cholecystotomy  and  cholelithotrity; 
one  gall-stone  removed;  gall-bladder  contracted;  numerous 
adhesions. 

After-History. — Cared;  well  in  1894. 

Gall-stone  :  Cholelithotrity  ;  Abnormal  Position  of  Gall-bladder. 

Case  42. — Mrs.  R.,  aged  forty,  seen  at  infirmary. 

Operation. — 2/4/1891.  Cholelithotrity  ;  gall-bladder  not  opened  ; 
one  stone,  the  size  of  a  filbert,  crushed  in  cystic  duct  ;  gall-bladder 
displaced  considerably  to  right. 

After-History. — Good  recovery;  well,  1894;  no  recurrence  of 
symptoms. 

Calcified  Hydatid  of  Liver  simulating  Enlarged  Gall-bladder  : 
Exploratory  Operation. 

Case  43. — Mr.  F.,  aged  fifty,  seen  at  infirmary.  Epigastric 
tumour,  with  pains  over  gall-bladder  region. 

Operation. — 13/4/1891.  Exploratory;  calcified  hydatid  tumour 
with  adhesions  found. 

After-History. — Recovery. 


APPENDIX  329 

Gall-stones  :  Cholc cystotomy  ;  Cholclitlwtvity. 

Case  44. —  Mrs.  S.,  aged  fifty,  seen  at  infirmary. 
Operation. — 7/5/1891.     Cholecystotomy  and  cholelithotrity  ;  five 
stones  crushed  with  the  fingers  and  forceps. 
After-History. — Good  recovery. 

Chronic  Catarrhal  Cholecystitis,  Kinking  of  Bile-duct,  Movable 
Kidney  :  Cholecystotomy. 

Case  45. — Mrs.  M.,  aged  fifty-nine,  seen  with  Dr.  Dobie, 
Keighley.  Distended  gall-bladder  ;  movable  right  kidney  ;  chronic 
catarrh  of  gall-bladder,  with  frequent  attacks  of  pain,  apparently 
due  to  kinking  of  cystic  duct  by  the  movable  kidney. 

Operation. — 5/1 2/1 891.     Cholecystotomy. 

After-History. — Good  recovery ;  there  had  been  no  recurrence 
of  symptoms  in  July,  1893. 

Tumour  of  Gall-bladder  :  Exploratory  Operation  ;  Resolution  of 

Tumour. 

Case  46.— Mrs.  R.,  aged  fifty,  seen  with  Dr.  Gordon  Black, 
Harrogate.    Solid  tumour  of  gall-bladder,  thought  to  be  malignant. 

Operation. — 14/1/1892.  Exploratory;  exploration  by  needles 
after  abdomen  had  been  opened. 

After-History. — Ultimate  complete  recovery  without  further 
treatment. 

Cancer  of  Liver  and  Gall-bladder  :  Cholecystotomy. 

Case  47. — Mrs.  P.,  aged  fifty-six,  seen  with  Dr.  McGregor 
Young,  Leeds.  Chronic  jaundice  with  attacks  of  pain  over  the 
liver ;  hemorrhagic  diathesis. 

Operation. — 1/2/1892.  Cholecystotomy;  cancer  of  gall-bladder 
and  liver  found  ;  chloride  of  calcium  used  before  the  operation  ; 
little  bleeding. 

After-History. — Recovery  ;   greatly  relieved  for  over  a  year. 

Gall-stones :  Cholecystotomy. 

Case  48. — H.  C,  female,  aged  forty-four,  seen  with  Dr.  Stewart, 
Batley. 

Operation. — 12/2/1892.  Cholecystotomy;  eight  gall-stones  re- 
moved from  gall-bladder,  fifteen  from  cystic  duct. 

After-History. — Cured. 

Gall-stones  :  Cholecystotomy  ;  Cholelithotrity. 

Case  49. — Mr.  O.,  aged  fifty-one,  seen  with  Dr.  McGregor, 
Huddersfield.     Jaundice  present. 


jj( 


DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


Operation. — 3/3/1892.       Cholecystotomy     and      cholelithotrity. 
Gall-stones  crushed  in  cystic  duct. 
After-History.  — Cured . 

Gall-stones,  Jaundice  :  Cholecystotomy ;  Cholelithotrity. 

Case  50. — Mr.  M.,  aged  thirty-seven,  seen  at  infirmary. 
Jaundice  present. 

Operation. — 10/3/1892.  Cholecystotomy  and  cholelithotrity; 
gall-stones  removed  from  gall-bladder  and  cystic  duct. 

After-History. — Recovery.  Biliary  fistula  persisted,  but  ulti- 
mately closed,  to  reopen  after  another  attack  of  biliary  colic 
followed  by  jaundice.     (See  Case  55.) 

Chronic  Pancreatitis  :  Cholecystotomy. 

Case  51. — Mr.  P.,  aged  thirty-two,  seen  with  Dr.  Woods, 
Killinghall,  and  Dr.  Barrs.  Deep  jaundice ;  distended  gall- 
bladder ;  emaciation  ;  no  pain  ;  extremely  feeble. 

Operation. — 1/4/1892.  Cholecystotomy;  no  gall-stones;  hard 
swelling  of  head  of  pancreas  ;  distended  gall-bladder. 

After-History. —  Patient  much  exhausted  and  emaciated  at  the 
time  of  operation  ;  almost  died  under  anaesthetic.  Died,  apparently 
from  shock,  on  the  second  day. 

Autopsy  and  microscopic  examination  showed  tumour  not  to  be 
cancer,  but  chronic  pancreatitis. 

Cancer  of  Liver  :  Exploratory  Operation. 

Case  52. — Mr.  D.,  aged  thirty-five,  seen  at  infirmary.  Malig- 
nant disease  of  the  liver ;  jaundice  with  pain  resembling  gall- 
stones. 

Operation. — 7/6/1892.     Exploratory. 

After-History. — Recovery  from  operation  and  returned  home. 

Gall-stones  in  Common  Duct :  Cholecystotomy  and  Cholelithotrity. 

Case  53.— Mrs.  R.,  aged  fifty-six,  seen  with  Dr.  Blomfield, 
Pontefract. 

Operation. — 1 5/6/1 892.  Cholecystotomy  and  cholelithotrity; 
gall-stones  in  gall-bladder  and  in  cystic  and  common  ducts ;  latter 
crushed,  former  removed. 

After -History.  —  Cured. 

Adhesions  of  Pylorus  to  Gall-bladder  :  Gastrolysis. 
Case  54.— Mr.  F.  T.  W.,aged  eighteen,  seen  with  Dr.  Walker, 
Kirkby  Stephen.     Recurrent  attacks  of  pain  in  hypochondrium. 


APPENDIX  331 

Operation. — 6/8/1892.  Exploratory ;  extensive  adhesions  of 
pylorus  to  gall-bladder  broken  down. 

After-History. — Recovery  ;  gained  2  stones  in  weight  after  the 
operation  ;  well,  1894. 

Biliary  Fistula  :  Cholecystectomy  ;  Cholcdochenterostomy. 

Case  55. —  Mr.  M.,  aged  thirty-eight,  seen  at  infirmary.  Biliary 
fistula  after  operation  five  months  previously. 

Operation. — 6/8/1892.  Cholecystectomy  and  choledochenter- 
ostomy  ;  dilated  cystic  duct  united  to  colon  by  small  decalcified 
bone  bobbin. 

After-History. — Perfectly  well  for  some  months,  after  which 
jaundice  recurred,  due  to  gall-stone  left  in  common  duct.  (See 
Case  59.) 

Gall-stones  in  Common  Duct,  Jaundice  :  Cholecystotomy  ; 
Cholelithotrity. 

Case  56. — Mrs.  T.,  aged  fifty,  seen  with  Dr.  Harwood,  Burnley. 
Jaundice  nine  months  ;  cholangitis. 

Operation. — 29/9/1S92.  Cholecystotomy  and  cholelithotrity; 
shrunken  gall-bladder ;  gall-stone  in  contracted  bladder  and 
several  in  cystic  and  common  ducts  crushed.  Case  had  been 
pronounced  malignant  by  a  consulting  physician,  and  operation 
not  advised. 

After-History. —  Good  recovery  ;  well,  1893. 

Gall-stones  in  Common  Duct,  Jaundice  :  Cholecystotomy. 

Case  57. — Mrs.  E.,  aged  fifty,  seen  with  Dr.  Clifton,  Sheffield. 
Jaundice  present  for  ten  months ;  ague-like  attacks  due  to  infec- 
tive cholangitis. 

Operation. — 4/10/1892.  Cholecystotomy.  Two  large  gall-stones 
in  gall-bladder,  one  in  common  duct  removed  by  scoop.  Cancer 
diagnosed  by  consulting  physician,  and  operation  not  advised. 

After-History. — Good  recovery  ;  well,  1893. 

Gall-stones  in  Common  Duct :  Cholecystotomy  ;  Cholelithotrity. 

Case  58. — Mrs.  P.,  aged  forty,  seen  at  infirmary. 

Operation. — 12/1/1893.  Cholecystotomy  and  cholelithotrity  ; 
six  gall-stones  removed  from  cystic  duct,  several  crushed  in 
common  duct. 

After -History. — Recovery.  Small  biliary  fistula  persisted,  but 
at  times  closed.     (See  Case  73.) 


332    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stone  in  Common  Duct :  Choledochotomy. 

Case  59. — Mr.  M.,  aged  thirty-eight,  seen  at  infirmary.  Jaun- 
dice present. 

Operation. — 28/1/1893.  Choledochotomy;  large  gall-stone  re- 
moved from  common  duct  through  incision,  which  was  afterwards 
sutured. 

After-History. — Faecal  extravasation  through  small  perforation 
in  colon,  caused  by  separating  adhesions  and  unrecognised  at 
the  time  of  operation.     Death  in  second  week. 

Gall-stones :  Cholecystotomy. 

Case  60. — Mrs.  B.,  aged  thirty-six,  seen  with  Dr.  Watts, 
Dewsbury. 

Operation.  —  24/2/1893.  Cholecystotomy;  six  large  stones 
removed. 

After-History. — Good  recovery  ;  well,  1896. 

Gall-stones,  Jaundice  ;  Cholecystotomy ;  Cholelithotrity. 

Case  61. — Mr.  O.,  aged  fifty-one,  seen  at  infirmary.  Jaundice 
present. 

Operation. — 3/3/1893.  Cholecystotomy  and  cholelithotrity  ;  con- 
tracted gall-bladder ;  several  stones  crushed  in  common  duct. 

After-History. — Complete  recovery  ;  quite  well,  1894. 

Gall-stones :  Cholecystotomy. 

Case  62. — A.  B.,  female,  aged  thirty-seven,  seen  at  infirmary. 
Operation. — 11/3/1893.    Cholecystotomy;  shrunken  gall-bladder; 
one  large  stone  in  cystic  duct  removed. 

After-History. — Cured  ;  well  when  last  seen. 

Gall-bladder  Colic,  Adhesions,  Dilated  Stomach,  Gastrolysis. 

Case  63. — Mr.  G.,  aged  thirty-nine,  seen  at  infirmary.  Dilata- 
tion of  stomach  following  on  history  of  gall-stones. 

Operation. — 22/3/1893.  Laparotomy  and  separation  of  adhesions ; 
no  gall-stones  found. 

After -History. — Good  recovery  ;  quite  well  three  months  after- 
wards. 

Gall-stones  :  Cholecystotomy. 

Case  64.— Mr.  H.,  aged  fifty,  seen  with  Dr.  Topham,  Halifax. 
Operation.— 1 1  \\\ 1893.      Cholecystotomy;     156    gall-stones    re- 
moved from  gall-bladder  and  cystic  duct. 
After-History. — Cured. 


APPENDIX  333 

Mucous  Fistula  :  Cholecystectomy. 

Case  65. — Mrs.  T.,  aged  forty-four,  seen  at  infirmary.  Mucous 
fistula  over  gall-bladder. 

Operation. — 28/4/1893.     Cholecystectomy. 
After -History. — Perfect  recovery  ;  well,  1894. 

Tumour  of  Gall-bladder  :  Exploratory  Operation  ;  Resolution  of 

Tumour, 

Case  66. — Mrs.  T.,  aged  fifty-four,  seen  at  infirmary. 

Operation. — 5/5/1893.  Exploratory  ;  cancer  of  the  gall-bladder  ; 
large,  hard  nodular  tumour  yielding  only  blood  to  exploring  syringe ; 
every  appearance  of  malignancy. 

After-History. — Recovery.  Wound  healed  by  first  intention, 
and  patient  reported  to  be  well  some  years  later. 

Gall-stones  :  Cholecyslotomy. 

Case  67. — Mrs.  B.,  aged  forty-four,  seen  at  infirmary. 
Operation. — 6/5/1893.    Cholecystotomy;  contracted  gall-bladder  ; 
two  stones  in  cystic  duct  crushed. 

After-History. — Good  recovery  ;  well  when  last  heard  of. 

Gall-stone  :  Cholecystotomy. 

Case  68. — Mrs.  G.,  aged  forty,  seen  at  infirmary. 

Operation. — 1 9/5/1893.  Cholecystotomy;  gall-stone  weighing 
112  grains  removed  from  cystic  duct. 

After-History.  —  Recovery  ;  perfectly  well  some  months  sub- 
sequently. 

Gall-stones :  Cholecystotomy. 

Case  69. — Mrs.  S.  J.  R.,  aged  thirty-five,  seen  with  Dr.  Taylor, 
Meadow  Lane. 

Operation. — 19/5/1893.  Cholecystotomy;  two  large  gall-stones 
in  cystic  and  common  duct ;  gall-bladder  contracted. 

After-History. — Cured  ;  well  in  1895. 

Gall-stone  in  Common  Duct :  Cholecystotomy ;  Cholelithotrity. 

Case  70. — Mrs.  S.,  aged  thirty-one,  seen  with  Dr.  Scatterty, 
Keighley.     Jaundice  present. 

Operation. — 25/5/1893.  Cholecystotomy;  stone  crushed  in 
common  duct. 

After-History.  —  Good  recovery  ;  quite  well  when  seen  some 
time  after. 


334    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones  :  Cholecystotomy. 

Case  71. — Mrs.  F.,  aged  fifty-four,  seen  with  Dr.  Rowe,  Leeds, 
and  Dr.  Mais,  Thorner. 

Operation. — 6/6/1893.  Cholecystotomy;  distended  gall-bladder  ; 
three  stones  removed  from  the  cystic  duct. 

After -History. — Good  recovery  ;  quite  well,  1894. 

Gall-stones  in  Common  Duct :  Cholecystotomy  ;  Cholelithotrity. 

Case  72. — Mr.  B.,  aged  fifty-eight,  seen  at  infirmary.  Jaundice 
present. 

Operation.  —  20/6/1893.  Cholecystotomy  and  cholelithotrity; 
several  large  stones  in  cystic  and  common  ducts  removed,  others 
crushed. 

After-History. — Recovery.  Bronchitis  third  week,  and  patient 
left  the  infirmary  at  his  own  request,  though  not  well. 

Biliary  Fistula  :  Cholecystenterostomy. 

Case  73. — Mrs.  P.,  aged  forty,  seen  at  infirmary.  Biliary 
fistula. 

Operation. — 31/7/1893.  Cholecystenterostomy  by  decalcified 
bone  bobbin. 

After-History. — Good  recovery  ;  quite  well,  1894. 

Gall-stones  in  Common  Duct :  Cholecystotomy  ;  Cholelithotrity. 

Case  74. — Mr.  G.,  aged  fifty-two,  seen  at  infirmary.  Jaundice 
present. 

Operation. — 24/8/1893.  Cholecystotomy;  large  stone  in  cystic 
duct ;  several  crushed  in  common  duct. 

After-History. — Good  recovery  ;  quite  well,  1894. 

Gall-stones  :  Cholecystotomy. 

Case  75. — Mrs.  C,  aged  thirty-five,  seen  with  Dr.  Mackenzie, 
Douglas,  Isle  of  Man.     Jaundice  present. 

Operation. — 4/9/1893.  Cholecystotomy  ;  twenty-seven  gall- 
stones removed  from  gall-bladder  and  cystic  duct. 

After-History. — Complete  recovery  ;  well,  1896. 

Gall-stones :  Cholecystotomy. 

Case  76. — Mrs.  B.,  aged  forty,  seen  with  Dr.  Hodgson  Wright, 
Halifax,  and  Dr.  Ozanne,  Harrogate.  Distended  gall  bladder ; 
slight  jaundice. 

Operation. — 26/9/1893.  Cholecystotomy;  six  stones  removed 
from  the  gall-bladder  and  cystic  duct. 

Afief-History. — Good  recovery;  perfectly  well,  February,  1895. 


APPENDIX  335 

Gall-stones  :  Cholecystotomy ;  Cholelithotrity. 

Case  77. — K.  B.,  female,  aged  forty-four,  seen  at  infirmary. 
Jaundice  present. 

Operation. — 28/9/1893.  Cholecystotomy  and  cholelithotrity  ; 
stones  removed  from  the  cystic  duct,  and  several  crushed  before 
removal  ;  extensive  adhesions. 

A ftev -History. — Good  recovery  ;  well  when  last  heard  of. 

Gall-stones,  Intestinal  Obstruction  ;  Cholecystotomy  ;  Cholelithotrity. 

Case  78. — Mrs.  R.,  aged  fifty-six,  seen  at  infirmary.  Jaundice 
present.     (For  previous  history,  see  p.  164.) 

Operation. — 21/10/1893.  Cholecystotomy  and  cholelithotrity; 
six  gall-stones  removed  and  several  crushed  in  the  common  duct. 

After-History. — Cured  ;  well  some  months  after. 

Gall-stones,  Fistula :  Cholecystotomy. 

Case  79. — Mrs.  C,  aged  thirty-five,  seen  with  Dr.  Walker, 
Redcar.     Sinus  discharging  bile  and  pus  at  umbilicus. 

Operation. — 14/11/1893.  Fistula  laid  open,  and  eighteen  gall- 
stones, together  with  pus  and  mucus,  removed  from  the  gall- 
bladder by  cholecystotomy,  but  because  of  the  suppuration  the 
ducts  were  not  explored. 

After-History. — Good  recovery  ;  March,  1894,  wrote  to  say  very 
well  except  for  a  small  mucous  fistula.     (See  Case  109.) 

Gall-stones  :  Cholecystotomy  ;  Cholelithotrity. 
Case  80. — M.  A.  K.,  female,  aged  thirty,  seen  at  infirmary. 
Operation. —  30/11/1893.      Cholecystotomy   and   cholelithotrity; 
five  gall-stones  removed. 
After-History. — Cured. 

Extravasation  of  Bile   due  to  ruptured  Bile-ducts,  Subdiaphragmatic 

A  bscess  :  Drainage. 

Case  81.— Mr.  P.,  aged  forty-five,  seen  with  Dr.  Braithwaite, 
Leeds.  After  symptoms  of  gall-stones  for  twenty-nine  years, 
acute  general  peritonitis  starting  over  the  gall-bladder. 

Operation. — 12/10/1893.  Rupture  of  bile-ducts  and  extravasation 
of  several  pints  of  bile,  with  pus,  found  at  the  operation.  Lapar 
otomy,  lavage,  and  drainage. 

After-History. — Perfect  recovery ;  patient  well  and  at  business 
within  two  months  ;  well  in  1895. 

Cancer  of  Liver  and  Gall-bladder  :  Exploratory  Operation. 
Case  82. — Mr.  E.,aged  twenty-seven,  seen  at  infirmary,  jaundice. 
Operation. — 18/1/1894.    Exploratory;  malignant  tumour  of  gall- 
bladder and  liver. 

After -History. — Recovery  from  operation, 


336    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones  :  Cholecystotomy. 

Case  83. — Mrs.  C,  aged  forty-five,  seen  at  infirmary. 

Operation. — 18/2/1894.  Cholecystotomy;  six  gall-stones  in 
gall-bladder,  and  twenty-three  in  cystic  duct. 

Aftev-History.  —  Good  recovery;  March,  1894,  writes  to  say 
1  better  than  for  years.' 

Gall-stones :  Cholecystotomy. 

Case  84. — M.  L.  S.,  female,  aged  thirty,  seen  at  infirmary. 
Distended  gall-bladder,  with  attacks  of  pain. 

Operation. — 20/2/1894.     Cholecystotomy  ;  gall-stones  removed. 
After -History. — Good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  85. — Mrs.  L.,  aged  thirty-two,  seen  with  Dr.  Macgregor 
Young,  Leeds.     No  jaundice  present. 

Operation. — 3/3/1894.  Cholecystotomy  ;  twenty  gall-stones  re- 
moved from  gall-bladder  and  cystic  duct. 

After-History. — Good  recovery  ;  well,  1897. 

Gall-stones  :  Cholecystotomy. 

Case  86. — Mrs.  E.,  aged  thirty-five.  Distended  gall-bladder  ; 
no  jaundice  present. 

Operation. — 7/3/1894.  Cholecystotomy  :  thirty-five  gall-stones 
removed. 

After-History. — Good  recovery  ;  well,  1897. 

Adhesions,  Spasmodic  Pain  and  Vomiting  :  Gastrolysis. 

Case  87. — Mr.  G.,  aged  thirty-nine.  History  of  cholelithiasis 
six  years  before ;  five  years'  history  of  pain,  vomiting,  etc.  ;  dilated 
stomach. 

Operation. — 1 2/3/1894.  Laparotomy;  separation  of  adhesions 
of  pylorus  to  gall-bladder. 

After-History. — Complete  recovery.  Gained  2  stones  in  weight 
in  three  months. 

Intestinal  Obstruction,   Volvulus,  Cholelithiasis  :  Laparotomy. 

Case  88. — Mrs.  O.,  aged  sixty,  seen  with  Dr.  Low'nds,  Doncaster. 
Acute  intestinal  obstruction ;  volvulus  of  small  intestine  after 
gall-stone  seizure.  Gall-stone  attacks  for  seven  years ;  acute 
obstruction  five  days. 

Operation. — 1 3/3/1 894.     Laparotomy;  untwisting  of  volvulus. 

After-History. — Complete  recovery  ;  perfectly  well  when  heard 
of  in  June,  1894. 


APPENDIX  337 

Gall-stones  :  Cholecystotomy. 

Case  8g. — Mr.  S.,  aged  fifty,  seen  with  Dr.  Eddison,  Leeds,  and 
Dr.  Swann,  Batley.     Spasms  for  three  years. 

Operation. — 24/5/1894.  Cholecystotomy;  ninety-six  gall-stones 
removed  from  the  gall-bladder  and  cystic  duct ;  drainage  four 
days. 

After- History. — Good  recovery  ;  well,  1897. 

Gall-stones,  Hourglass  Gall-bladder  :  Cholecystotomy. 

Case  90. — Mrs.  L.,  aged  thirty-nine,  seen  with  Dr.  Helm, 
Sheffield.     Ten  years'  history  ;  no  jaundice. 

Operation. — 29/5/1894.  Cholecystotomy.  Hourglass  contrac- 
tion of  gall-bladder  ;  forty-nine  gall-stones  removed  ;  drainage. 

After-History. — Complete  recovery  ;  well,  1901. 

Jaundice,  Abscess  with  Tumour  of Liver  :  Laparotomy;  Drainage. 

Case  91. — Mr.  P.,  aged  forty-nine,  seen  at  infirmary.  Chronic 
catarrh  of  bile-ducts  and  jaundice  ;  recurrent  attacks  of  pain. 

Operation. — 30/5/1894.  Laparotomy  ;  tumour  of  liver  (pro- 
bably soft  carcinoma)  with  suppuration  ;  drainage. 

After -History. — Left  the  infirmary  improved  ;  sinus  remain- 
ing. 

Gall-stones,  Jaundice,  and  Infective  Cholangitis  :  Cholecystotomy. 

Case  92. — Mrs.  M.,  aged  forty-six,  seen  with  Dr.  Townsend, 
Cork.  Excessive  vomiting  for  six  weeks,  and  during  past  three 
weeks  had  subsisted  on  nutrient  enemas  ;  very  ill ;  jaundice  and 
infective  cholangitis  present. 

Operation. — 9/6/1894.  Cholecystotomy;  gall-bladder  contracted 
and  surrounded  by  firm  adhesions ;  eighteen  gall-stones  removed 
from  ducts,  and  gall-bladder  drained  without  complete  suture  to 
parietes. 

After-History. — Death  from  exhaustion  due  to  continuation  of 
vomiting  on  twelfth  day  after  operation  ;  no  peritonitis. 

Gall-stones,  Jaundice  :  Cholecystotomy  ;  Gastrolysis. 

Case  93. — Mrs.  P.,  aged  forty-three,  seen  at  infirmary.  Spasms 
for  ten  months  ;  jaundice  present;  patient  emaciated  and  extremely 
weak. 

Operation. — 18/6/ 1894.  Cholecystotomy  ;  160  gall-stones  the 
size  of  peas  removed  from  the  gall-bladder  and  cystic  duct. 
Drainage  ;  adhesions  to  pylorus,  etc.,  detached. 

A fter- History. — Complete  recovery. 

22 


338    DISEASES  OE  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones  :  Cholecystotomy. 
Case  94. — Mrs.  A.,  aged  forty,  seen  at  infirmary. 
Operation. — 1 9/7/1 894.     Cholecystotomy  ;     160   gall-stones    re- 
moved. 

After-History. — Good  recovery. 

Gall-stones  in  Common  Duct,  Biliary  Fistula  :  Cholelithotrity. 

Case  95. — Mr.  R.,  aged  thirty-seven,  seen  at  infirmary.  Ad- 
mitted for  biliary  fistula  following  on  cholecystotomy,  performed 
at  Wolverhampton  some  months  before,  when  ten  gall-stones 
were  removed. 

Operation. — 10/8/1894.  Cholecystotomy  and  cholelithotrity;  two 
stones  crushed  in  the  common  duct. 

After-History. — Cured. 

Gall-stones,  Jaundice,  Fistula  of  Duodenum,  Abscess  of  Liver  :  Chole- 
cystotomy. 

Case  96. — Mr.  V.,  aged  sixty,  seen  with  Dr.  Carter,  Ilkley. 
Jaundice  present. 

Operation. — 1 8/8/1 894.  Cholecystotomy  ;  thirty  gall-stones  re- 
moved from  a  cavity  in  the  liver;  fistulous  ulceration  into  the 
duodenum  closed. 

After-History. — Recovery.  Some  months  after,  died  from  cancer 
of  the  liver. 

Catarrhal  Cholecystitis  :  Cholecystotomy  ;  Gastrolysis. 

Case  97. — Mrs.  W.,  aged  thirty-four,  seen  with  Dr.  Byers  and 
Dr.  Steen,  Belfast. 

Operation. — 6/9/1894.  Cholecystotomy,  with  separation  of  ad- 
hesions ;  gall-bladder  filled  with  thick  mucus  and  bile  ;  chronic 
cholecystitis  ;  extensive  adhesions  of  gall-bladder  to  omentum  and 
stomach  ;  no  gall-stones  ;  drainage. 

After -History. — Good  recovery  ;  well  when  heard  of  in  1896. 

Cancer  of  Liver,  Jaundice  :  Exploratory  Laparotomy. 

Case  98. — Mrs.  H.,  aged  sixty,  seen  with  Dr.  Broughton, 
Dewsbury. 

Operation. — 12/9/1.S94.  Laparotomy;  cancerous  nodules  on 
liver  ;  jaundice  present ;  gall-bladder  dilated. 

After-History. — Recovered  from  the  operation,  but  ultimately 
died  some  weeks  after  from  the  progress  of  the  disease. 

Intestinal  Obstruction  from  Gall-stone  in  Ileum :  Enterotomy. 

Case  99. — Mrs.  L.,  aged  forty-five,  seen  with  Dr.  Raimes  and 
Dr.  Anderson,  York.     Acute  intestinal  obstruction  for  five  days. 


APPENDIX  339 

Operation. — 13/9/1894.  Laparotomy;  large  gall-stone  found  in 
ileum,  removed  by  incising  intestine. 

After-History. — Complete  recovery  ;  patient  well,  1896. 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Cask  100. — Mrs.  T.,  aged  thirty-six,  seen  with  Dr.  Tweedy, 
Northallerton. 

Operation. — 23/10/1894.  Cholecystotomy;  8  ounces  of  milky 
fluid  removed  from  the  gall-bladder  ;  three  stones  the  size  of 
nutmegs  removed  from  the  cystic  duct ;  drainage  for  three  days. 

After- History. — Complete  recovery,  and  gained  nearly  1  stone  in 
weight  in  a  month  ;  well  1896. 

Chronic  Cholecystitis  :  Cholecystotomy. 

Case  ioi. — Mrs.  G.,aged  sixty,  seen  with  Dr.  Clifton,  Sheffield. 
Spasmodic  intermittent  pain. 

Operation. — 10/11/1894.  Cholecystotomy;  gall-bladder  filled 
with  thick  mucus  and  bile ;  chronic  cholecystitis  ;  drainage. 

After-History. — Cured  ;  quite  well  in  1896. 

Gall-stones  ;  Cholecystotomy. 
Case  102. — Mr.  C,  aged  forty-eight,  seen  at  infirmary. 
Operation. — 2/12/1894.     Cholecystotomy  ;  gall-stones  removed. 
After -History. — Good  recovery. 

Cancer  of  Pancreas,  Jaundice  :  Cholecystotomy. 

Case  103. — Mr.  A.,  aged  fifty,  seen  with  Dr.  Menzies,  Edin- 
burgh.    Persistent  jaundice. 

Operation. — 10/12/ 1894.  Laparotomy;  drainage  of  gall-bladder, 
with  decided  relief  for  a  time  ;  cancer  of  the  pancreas. 

After-History. — Recovered  from  the  operation1  and  returned 
home  at  the  month  end,  but  died  some  months  later. 

Gall-stones  in  Common  Duct :  Cholecystotomy  ;  Cholelithotrity. 

Case  104. — Mr.  P.,  aged  fifty-five,  seen  at  the  infirmary. 
History  of  attacks  for  eight  years  ;  jaundice  at  times. 

Operation. — 8/1/1895.  Cholecystotomy  and  cholelithotrity  ; 
eleven  stones  removed ;  several  crushed  in  the  common  duct  ; 
drainage  of  gall-bladder. 

After- History. — Recovery;  fistula  persisting.     (See  Case  121.) 

Gall-stones  :  Cholecystotomy. 
Case    105. — Mr.  J.,   aged  fifty,  seen   at  the  infirmary.     First 
attack  twelve  years  ago  ;  no  tumour  felt ;  had  passed  eight  stones 
at  various  times. 


340    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation. — 13/2/1895.  Cholecystotomy  ;  five  stones  removed  ; 
drainage. 

After-History. — Cured. 

Gall-stones  :  Empyema  of  Gall-bladder ;  Cholecystotomy. 

Case  106. — Mr.  C,  aged  fifty,  seen  with  Dr.  Husband,  Ripon. 
Empyema  of  gall-bladder  ;  no  jaundice  present. 

Operation. — 8/3/1895.  Cholecystotomy;  sixteen  gall-stones  re- 
moved from  the  gall-bladder  and  cystic  duct ;  2  ounces  of  muco- 
pus  in  gall-bladder  ;  drainage,  four  days. 

After- History. — Returned  home  well  in  three  weeks  ;  well, 
1897. 

Gall-stones :  Cholecystotomy. 

Case  107. — Mr.  C,  aged  fifty-one,  seen  with  Dr.  Fairburn, 
Doncaster.     Slight  jaundice. 

Operation. — 14/3/1895.  Cholecystotomy  ;  720  gall-stones  re- 
moved ;  drainage. 

After -History. — Cured. 

Gall-stones  :  Cholecystotomy. 

Case  108. — Mr.  D.,  aged  forty-four,  seen  at  the  infirmary. 
History,  two  years  with  jaundice. 

Operation. — 20/3/1895.  Cholecystotomy  ;  large  stone  removed 
from  the  cystic  duct. 

After-History. — Cured. 

Gall-stones  :  Cholecystotomy. 

Case  109. — Mrs.  C,  aged  thirty-seven,  seen  with  Dr.  de  Legh, 
Redcar.     Mucous  fistula  connected  with  gall-bladder. 

Operation. — 18/4/ 1895.  Cholecystotomy  ;  gall-stones  removed 
from  the  cystic  duct. 

After-History. — Good  recovery  ;  well,  1900. 

Gall-stones  :  Cholecystotomy. 

Case  iio. — Mrs.  P.,  aged  fifty-five,  seen  at  the  infirmary. 
Operation. — 11/4/1895.     Cholecystotomy;  one   large   gall-stone 
removed  the  size  of  a  cherry. 

After -History. — Cured;  well,  1896. 

Gall-stones :  Cholecystectomy. 

Case  hi. — Mr.  M.,  aged  forty-six,  seen  with  Dr.  Keyes,  New 
York,  and  Dr.  MacGeagh,  London.  Frequent  seizures  of  intense 
pain  like  cholelithiasis,  which  had  doubtless  been  the  cause  of  the 
cholecystitis  and  cholangitis. 


A  PPENDIX  34 1 

Operation. — 2/5/1895.  Cholecystectomy  ;  gall-bladder  cavity 
contracted  ;  walls  hypertrophied  and  adherent. 

After-History. — Good  recovery,  and  nine  months  later  was  in 
perfect  health. 

Gall-stones  :  Cholecystotomy. 

Case  112. — Mrs.  B.,  aged  forty-one,  seen  at  the  infirmary. 
Attacks  of  pain  with  jaundice  for  eleven  years. 

Operation. — 15/5/1895.  Cholecystotomy;  forty-three  stones  re 
moved,  six  the  size  of  cherries. 

After-History. — Cured. 

Gall-stones  in  Hepatic  and  Common  Ducts  :  Cholecystotomy  and 

Cholelithotrity. 

Case  113. — Mrs.  G.,  aged  forty-five,  seen  with  Dr.  Meade, 
Bradford. 

Operation. — 20/5/1895.  Cholecystotomy  and  cholelithotrity  ; 
eight  gall-stones  removed  from  the  cystic  duct,  several  crushed 
in  the  common  and  hepatic  ducts  ;  drainage. 

After-History. — Completely  cured;  well  in  1897. 

Gall-stones :  Cholecystotomy. 

Case  114. — Mr.  S.,  aged  thirty-five,  seen  at  the  infirmary. 
Attacks  of  pain  for  ten  years  ;  passed  fourteen  gall-stones. 

Operation. — 27/5/1895.  Cholecystotomy  ;  307  small  and  5  large 
stones  removed. 

After-History. — Cured;  well,  1896. 

Spasmodic  Pain  resembling  Gall-stone  Attacks  :  Gastrolysis. 

Case  115. — Mr.  L.,  aged  twenty-five,  seen  at  infirmary.  Attacks 
of  spasms  for  some  months. 

Operation. — 6/6/1895.  Laparotomy  and  separation  of  adhesions  ; 
adhesions  around  pylorus  and  gall-bladder. 

After-History. — Cured. 

Biliary  Fistula :  Cholecystendysis. 

Case  116. — Mrs.  C,  aged  thirty-six,  seen  with  Dr.  Salter, 
Scarborough.  Had  biliary  fistula  following  operation  at  another 
hospital,  when  eighteen  stones  were  removed. 

Operation. — 3/7/1895.  Cholecystotomy  and  cholecystendysis; 
gall-bladder  detached,  the  edges  inverted  and  sutured. 

After-History. — Cured. 


342    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones  :  Cholecystotomy ;  Gastrolysis. 

Case  117. — Mrs.  D.,  aged  forty-one,  seen  with  Dr.  Rowe, 
Leeds.  Severe  attack  of  pain  seven  months  ago ;  numerous 
seizures  since. 

Operation. — 4/7/1895.  Cholecystotomy  ;  one  large  stone  re- 
moved;  adhesions  to  pylorus,  etc.,  detached. 

After -History. — Cured. 

Chronic  Pancreatitis  :  Cholecystenterostomy. 

Case  118. — Mrs.  C,  aged  fifty-one,  seen  with  Dr.  Clarke,  Don- 
caster.     Persistent  jaundice  ;  chronic  pancreatitis. 

Operation. — 1 5/7/1 895.  Cholecystenterostomy  (Murphy'sbutton); 
several  stones  removed  and  crushed ;  tumour  of  pancreas  felt. 
The  sequel  shows  that  the  tumour  was  inflammatory. 

After -History. — Recovered,  but  the  Murphy's  button  was  never 
found ;  well,  1898. 

Gall-stones  and  Cancer  of  the  Liver  and  Gall-bladder  :  Cholecystotomy. 

Case  119. — Mr.  L.,  aged  sixty-two,  seen  at  the  infirmary. 
Spasms  and  jaundice  for  twenty  years. 

Operation. — 1 8/7/1 895.  Cholecystotomy  ;  thirty-two  gall-stones 
removed  ;  drainage  ;  cancer  of  the  liver  and  gall-bladder. 

After-History. — Recovered  from  the  operation  ;  relief  from  pain 
and  from  jaundice. 

Gall-stones  :  Cholecystotomy  ;  Cholelithotrity. 

Case  120. — Mr.  W.,  aged  forty-two,  seen  with  Dr.  Sproule, 
Mirfield.     Patient  had  never  been  jaundiced. 

Operation. — 23/7/1895.  Cholecystotomy  and  cholelithotrity; 
one  large  stone  in  the  cystic  duct  was  crushed  ;  drainage. 

After-History. — Good  recovery  ;  well,  1897. 

Mucous  Fistula  following  Cholecystotomy  :  Cholecystectomy  and 
C  holedochenterosto  my ' . 

Case  121. — Mr.  P.,  aged  fifty-five,  seen  at  the  infirmary. 
Operation  undertaken  for  closing  a  mucous  fistula. 

Operation. — 24/7/1895.  Cholecystectomy  and  choledochenter- 
ostomy;  the  gall-bladder  was  found  to  be  forming  a  tumour  with 
walls  \  inch  to  J  inch  thick.  Cholecystectomy  was  performed, 
and  the  open  end  of  the  cystic  duct  connected  to  the  small  bowel 
by  means  of  a  Murphy's  button. 

After-History. — Completely  cured,  and  in  good  health,  1896. 


APPENDIX  343 

Cancer  of  Pancreas  and  Liver  :  Exploratory  Operation. 

Case  122. — Mr.  G.,  aged  forty,  seen  with  Dr.  Bronner,  Brad- 
ford.    Persistent  jaundice. 

Operation. — 27/7/1895.  Laparotomy  ;  cancer  of  the  liver  and 
pancreas. 

After-History. — Recovered  from  the  operation  ;  relief  for  some 
weeks. 

Chronic  Pancreatitis,  Jaundice  :  Cholec y stent er ost omy . 

Case  123. — Mr.  J.  W.  B.,  aged  fifty-six,  seen  with  Dr.  Lee, 
Dewsbury.     Pain  and  jaundice  for  .a  year. 

Operation.—  27/8/ 1895.  Cholecystenterostomy  ;  distended  gall- 
bladder ;  no  calculi ;  stenosis  of  the  common  duct  from  swelling  of 
head  of  pancreas ;  3  ounces  of  fluid  tinged  with  blood  removed 
from  the  gall-bladder ;  probably  chronic  pancreatitis. 

After-History. — Good  recovery ;  Murphy's  button  passed  in  two 
weeks.  Report,  1897,  to  sav  that  tne  patient  had  gained  weight 
after  the  operation,  and  had  been  at  work  ever  since,  though  he 
had  had  occasional  attacks  of  pain  and  jaundice. 

Gall-stones  :  Cholecystotomy. 

Case  124. — Mrs.  J.  O.  F.,  aged  thirty-five,  seen  with  Mr.  H.  B. 
Hewetson.  Ten  years'  history  of  spasms  with  intermittent 
jaundice. 

Operation. — 10/9/1895.  Cholecystotomy  ;  thirty  stones  removed  ; 
adhesions  broken  down. 

After-History. — Cured;  well,  1897. 

Gall-stones,  Jaundice  :  Choledochotomy  and  Cholecystotomy. 

Case  125. — Mr.  W.,  aged  fifty-two,  seen  at  the  infirmary. 
Slight  jaundice. 

Operation. — 26/10/1895.  Cholecystotomy  and  choledochotomy; 
gall-bladder  ruptured  suddenly  during  separation  of  adhesions ; 
one  stone  removed,  f  inch  in  diameter,  through  an  incision  in  the 
common  duct ;  drainage  through  the  loin. 

After-History. — Cured;  September,  1897,  passed  two  gall-stones 
per  anum  ;  well  in  the  interval  and  subsequently. 

Cancer  of  Pancreas  :  Laparotomy. 

Case  126. — Mr.  H.,  aged  sixty,  seen  with  Dr.  Haynes,  Low 
Moor.     Jaundice  and  pain. 

Operation. — 18/11/1895.     Laparotomy;  cancer  of  pancreas. 
After-History. — Decided  relief  for  several  months. 


344    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones,  Cancev  of  Gall-bladder  and  Liver  :  Cholecystectomy  ; 

Hepatectomy. 

Case  127. — Mrs.  W.,  aged  fifty-four,  seen  with  Dr.  O'Connell, 
Keighley. 

Operation. — 23/11/1895.  Cholecystectomy  and  hepatectomy; 
two  gall-stones  removed  from  the  gall-bladder  ;  gall-bladder  dis- 
tended and  dilated/with  thick  material  like  putty  ;  walls  infiltrated 
with  malignant  disease ;  cancer  in  the  cystic  duct ;  gall-bladder 
excised  with  h  pound  of  liver. 

After-History. — The  patient  improved  and  remained  well  till 
February  27,  1896,  when  she  returned  with  a  superficial  nodule 
in  the  abdominal  wall,  which  was  excised.  She  died  some  months 
afterwards  from  a  recurrence  of  the  disease.  Case  reported  at 
the  Clinical  Society,  1896. 

Gall-stones,  Jaundice  :  Cholecystotomy. 

Case  128. — Mr.  M.,  aged  forty-three,  seen  at  the  infirmary. 
Jaundice  present. 

Operation. — 28/11/1895.  Cholecystotomy;  forty-eight  stones 
removed ;  drainage. 

After-History. — Cured. 

Gall-stones,  Jaundice :  Cholecystotomy. 

Case  129. — J.  M.,  female,  aged  thirty-two,  seen  at  the  infirmary. 
Attacks  of  pain  with  jaundice  for  eight  years.  After  each  attack 
passed  four  or  five  stones. 

Operation. — 3/12/1895.  Cholecystotomy;  gall-bladder,  cystic 
and  common  ducts  packed  with  stones — 129  removed. 

After-History. — Cured. 

Painful  Spasms  due  to  kinking  of  Bile-duct  and  of  Pylorus,  Dilatation 

of  Stomach  :  Gastrolysis. 

Case  130. — Mr.  L.,  aged  forty-six,  seen  with  Dr.  Lownds, 
Newcastle. 

Operation. — 9/12/1895.  Laparotomy  with  separation  of  adhe- 
sions ;  adhesions  around  pylorus,  gall-bladder,  and  liver,  causing 
kinking  and  dilatation  of  stomach,  probably  due  to  gall-stones 
which  had  been  passed  before  operation. 

After-History. — Cured  ;  well  in  1 897,  and  had  gained  a  stone  in 
weight. 

Painful  Spasms,  Duct  Adhesions,  Dilated  Stomach:  Separation  of 
Adhesions  and  Pyloroplasty. 

Case  131. — Mrs.  W.,  aged  twenty-nine,  seen  with  Dr.  Salter, 
Scarborough. 


APPENDIX  345 

Operation. — 14/12/1895.  Laparotomy  with  separation  of  adhe- 
sions ;  adhesions  around  pylorus,  gall-bladder,  and  liver,  causing 
kinking  and  dilatation  of  the  stomach,  with  stricture  of  the  pylorus, 
probably  due  to  gall-stones  which  had  been  passed  before  opera- 
tion ;  pyloroplasty  performed. 

After-History. — Cured  ;  well,  1899. 

Gall-stones,  Tumour  of  Gall-bladder,  Pregnancy  :  Cholecystotomy. 

Case  132. — Mrs.  W.,  aged  thirty-seven,  seen  with  Dr.  James, 
Oulton.  Gall-stone  attacks  associated  with  pregnancy  (sixth 
month);  patient  very  weak. 

Operation. — 17/ 12/ 1895.  Cholecystotomy;  gall-bladder  con- 
tained 8J  ounces  of  fluid  and  seven  large  stones. 

After-History. — Owing  to  a  disturbance  in  the  ward  one  night,  a 
week  after  the  operation,  patient  aborted,  but  made  a  complete 
recovery.     (See  Case  146.) 

Jaundice,  Cancer  of  Common  Duct :  Exploratory  Laparotomy. 

Case  133. — Mrs.  S.,  aged  fifty,  seen  with  Dr.  Booth,  Grimsby. 
Persistent  jaundice  ;  gall-stones. 

Operation. — 4/1/1896.  Laparotomy  ;  extensive  malignant  disease 
of  cystic  and  common  ducts. 

After-History. — Recovered  from  the  operation,  and  was  relieved 
for  a  time,  but  died  six  or  eight  months  afterwards. 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Case  134. — Mrs.  B.,  aged  thirty-six,  seen  with  Dr.  Taylor, 
Chester. 

Operation. — 12/1/1896.  Cholecystotomy  ;  three  large  gall-stones 
impacted  in  cystic  duct ;  empyema  of  the  gall-bladder  ;  drainage. 

After-History. — Cured;  well,  1899. 

Cancer  of  Gall-bladder  and  Liver  :  Exploratory  Operation. 

Case  135. — Mr.  D.,  aged  fifty-two,  seen  at  the  infirmary. 

Operation. /2/1896.    Laparotomy;  no  stone  found  ;  drainage; 

malignant  disease. 

After-History. — Recovery  from  operation,  and  returned  home. 

Gall-stones  in  Common  Duct :  Cholecystotomy ;  Cholelithotrity. 

Case  136. — Mrs.  S.,  aged  fifty-one,  seen  with  Dr.  Barrs. 
Slight  jaundice  ;  infective  cholangitis. 

Operation. — 1 7/2/1 896.  Cholecystotomy  and  cholelithotrity  ; 
forty  gall-stones  removed  from  gall-bladder  and  cystic  duct,  and 
two  crushed  in  the  common  duct ;  wound  healed  twenty-seventh 
day. 

After-History. — Cured  ;  well,  January,  1897. 


346    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones :  Cholecystotomy. 

Case  137. — Mrs.  G.,  aged  forty,  seen  with  Dr.  Burnie,  Brad- 
ford. 

Operation. — 5/3/1896.  Cholecystotomy  ;  eight  stones  removed 
from  the  gall-bladder  ;  ducts  apparently  clear. 

After '-History. — Recovery  ;  several  small  stones  passed  through 
fistula,  which  was  kept  open  for  several  weeks,  but  ultimately 
closed  spontaneously  ;  patient  now  well. 

Gall-stones  :  Cholecystotomy . 

Case  138. — Mrs.  H.,  aged  fifty,  seen  at  the  infirmary. 
Operation. — 1 7/3/1896.       Cholecystotomy;    sixteen    gall-stones 
removed,  three  as  large  as  Brazil  nuts. 
After-History. — Cured. 

Adhesions  around  Gall-bladder  and  to  Stomach  :  G  astro  lysis,  etc. 

Case  139. — Mrs.  F.,  aged  forty-four,  seen  at  the  infirmary. 
Pains  over  gall-bladder  region  resembling  cholelithiasis. 

Operation. — 23/6/1896.  Exploratory;  no  gall-stones  found  ;  ad- 
hesions separated. 

After-History,  —Cured  ;  in  May  the  patient  said  she  was  better 
than  for  many  months. 

Cancer  of  Gall-bladder  and  Stomach,  Jaundice  :  Exploration. 

Case  140. — Mr.  P.,  aged  fifty-three,  seen  at  the  infirmary. 
Jaundice  present. 

Operation. — 26/3/1896.  Laparotomy;  malignant  disease  in  the 
gall-bladder,  secondary  to  pyloric  cancer. 

After- History. — Recovered  from  the  operation,  but  was  un- 
relieved. 

Gall-stones,  Jaundice,  Cholecystitis  :  Cholecystectomy. 

Case  141. — Mrs.  C,  aged  forty-seven,  seen  at  the  infirmary. 
Jaundice  present. 

Operation. — 2/4/1896.  Cholecystectomy;  eighteen  stones  re- 
moved ;  adhesions  very  firm  and  gall-bladder  shrunken  ;  cystic 
duct  ligatured,  and  the  gall-bladder  removed. 

After-History. — Deatli  ;  ligature  slipped  from  the  duct  on  the 
second  day,  and  bile  became  extravasated,  producing  toxaemia 
and  peritonitis.  1  was  unfortunately  absent  at  the  time,  or  should 
have  reopened  the  abdomen.  A  stone  was  found  in  the  diverticu- 
lum of  Yater. 


APPENDIX  347 

Cancer  of  Gall-bladder  :  Exploration. 

Case  142. — Mr.  R.,  aged  sixty-two,  seen  with  Dr.  Gibson, 
Kirkby  Stephen.  Jaundice  present ;  tumour  in  gall-bladder 
region. 

Operation. — 1/6/1896.  Exploratory;  malignant  disease  of  liver 
and  gall-bladder. 

After-History. — Recovery  from  operation. 

Chronic  Jaundice,  Malignant  Disease  of  Pancreas  :  Exploration. 

Case  143. — Mrs.  H.,  aged  thirty-two,  seen  with  Dr.  Sharpe, 
Matlock.  Persistent  and  deep  jaundice,  seventeen  months  ;  fre- 
quent and  various  haemorrhages  for  several  months. 

Operation. — 8/6/1896.  Exploratory  ;  tight  stricture  of  the 
common  duct ;  no  gall-stones  found ;  questionable  malignant 
disease  of  pancreas. 

After-History. — Death  occurred  from  shock  twenty-four  hours 
after  operation. 

Gall-stones  :  CJwlecystotomy. 

Case  144. —  Mrs.  R.,  aged  thirty-seven,  seen  at  the  infirmary. 
Operation. — 23/6/1896.     Cholecystotomy  ;  thirty-nine  gall-stones 
removed  ;  drainage. 
After-History. — Cured. 

Gall-stones,  Jaundice  :  Choledochotomy  ;  Cholecystotomy. 

Case  145. — Mrs.  F.,  aged  forty-four,  seen  at  the  infirmary.  Deep 
jaundice  present. 

Operation. — 25/6/1896.  Numerous  gall-stones  removed  from 
the  gall-bladder  ;  the  common  duct  was  blocked  by  a  large  stone, 
which  was  removed  by  incising  the  duct  ;  gall-bladder  distended 
and  much  thickened  ;  drainage. 

After -History. — Cured. 

Gall-stones,  Jaundice  :  C  ho  key  stent erostomy. 

Case  146. — Mrs.  W.,  aged  thirty-seven,  seen  at  the  infirmary. 
This  case  was  operated  on  during  pregnancy,  December  17,  1895, 
and  returned  on  account  of  pain  and  jaundice. 

Operation.  —  27/5/1896.  Cholecystenterostomy  ;  seven  large 
stones  removed,  and  gall-bladder  fixed  to  intestine  by  a  Murphy's 
button. 

After -History. — Recovery  ;  button  never  found  ;  patient  left  the 
hospital  well. 


348    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Chronic  Pancreatitis,  Biliary  Fistula  :  Cholecyst enterostomy. 

Case  147. — Mr.  T.,  aged  thirty-seven,  seen  with  Dr.  Sykes, 
Barnsley.  Biliary  fistula  following  operation  at  St.  Bartholomew's 
Hospital ;  persistent  jaundice,  probably  chronic  pancreatitis. 

Operation.  —  1 3/7/1 896.  Cholecystenterostomy  (Murphy's 
button) ;  no  stones  found  ;  tumour  of  pancreas  indefinitely  felt 
through  adhesions. 

After -History. — Good  recovery  ;  bile  all  passing  into  the  bowel, 
and  wound  healed. 

Gall-stones,  Cancer  of  Liver  :  Exploratory  Operation. 

Case  148. — Mrs.  S..  seen  with  Dr.  Empey,  Steeton.  Persistent 
jaundice. 

Operation. — 1 3/7/1896.  Exploratory;  gall-stones  in  shrunken 
gall-bladder  and  in  common  duct ;  extensive  cancer  of  the  liver  ; 
operation  not  proceeded  with  ;  haemorrhage  from  wound  after- 
wards, but  controlled  by  calcium  chloride. 

After-History. — Recovered  from  the  operation  and  lived  four 
months. 

Cancer  of  Pancreas,  Jaundice  :  Cholecystenterostomy. 

Case  149. — Mr.  S.,  aged  forty-nine,  seen  at  the  infirmary. 
Jaundice  continuous  for  four  months. 

Operation. — 17/7/1896.  Cholecystenterostomy;  cancer  of  the 
pancreas  and  common  duct ;  distended  gall-bladder ;  no  gall- 
stones found. 

After-History. — Death  ;  intraparietal  and  intraperitoneal  haemor- 
rhage ;  no  peritonitis ;  patient  very  exhausted  at  the  time  of 
operation,  but  lived  a  week  after. 

Gall-stone  in  Common  Duct :  Choledochostomy  :  Drainage  of 

Duct. 

Case  150. — Mr.  C,  aged  twenty-five,  seen  at  the  infirmary. 
Jaundice  present. 

Operation. — 18/7/ 1896.  Choledochostomy;  large  gall-stone,  size 
of  small  hen's  egg,  in  cystic  and  common  duct  crushed  ;  cystic 
duct  dilated  and  much  longer  than  the  gall-bladder  ;  drainage  of 
duct. 

After-History. — Good  recovery. 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Case  151. — Mrs.  S.,  aged  thirty-four,  seen  with  Dr.  Patterson, 
Dalton-in-Furness.     Slight  jaundice  present. 

Operation. — 27/7/1896.    Cholecystotomy  ;  2  ounces  of  thin  pus  in 


A  PPENDIX  349 

the  gall-bladder;  two   stones   the   size  of  cherries   in  the   cystic 
duct ;  tense  adhesion  to  duodenum  separated. 
After- History. — Complete  recovery. 

Catarrhal  Cholangitis,  Jaundice,  Hydatid  Tumour  :  Ilepatotomy  ; 

Cholecystotomy. 

Case  152. — Mr.  G.,  aged  fifty-four,  seen  with  Dr.  Sadler, 
Barnsley.  Persistent  jaundice  for  several  months,  and  loss  of  21 
pounds  in  weight  ;  chronic  catarrh  of  gall-bladder  and  bile-ducts  ; 
large  fluctuating  tumour  of  liver  reaching  below  the  umbilicus. 

Operation.  —  31/7/1896.  Hepatotomy  and  cholecystotomy; 
hydatid  cyst  removed  ;  drainage. 

After -History. — Recovery  ;  jaundice  disappearing  slowly  within 
two  months  ;  quite  well,  January,  1897. 

Gall-stones,  Jaundice,  Suppurative  Cholangitis  :  Cholecystotomy. 

Case  153. — Mrs.  E.,  aged  thirty-eight,  seen  with  Dr.  Mac- 
kenzie, Bradford.  Symptoms  of  gall-stones  for  years,  acute  for 
two  months  ;  jaundice  and  suppurative  cholangitis  present. 

Operation. — 20/8/1896.  Cholecystotomy  ;  two  gall-stones  re- 
moved ;  contracted  gall-bladder,  with  numerous  adhesions. 

After-History. — Oozing  from  torn  adhesions  led  to  death  from 
haemorrhage,  which  was  concealed  at  first ;  no  vessel  of  any  size 
could  be  found,  but  every  point  bled.  Calcium  chloride  inadver- 
tently omitted  subsequent  to  operation. 

Gall-stones  :  Cholelithotrity. 

Case  154. — Mrs.  H.,  aged  thirty-eight,  seen  at  the  infirmary. 
Spasms  for  twelve  years. 

Operation. — 27/8/1896.  Cholelithotrity;  gall-bladder  shrunken 
and  adherent  to  surrounding  structures  ;  too  small  to  bring  to  the 
surface  ;  gall-stones  found  and  crushed. 

After-History. — Cured. 

Spasms,  Jaundice,  Adhesions  binding  down  Bile-ducts  separated  : 

Cholecystotomy. 

Case  155. — Mrs.  T.,  aged  fifty-six,  seen  at  the  infirmary. 
Spasms  almost  continuous  for  six  months  ;  jaundice  and  rigors ; 
cholangitis. 

Operation. — 15/10/1896.  Cholecystotomy;  no  gall-stones 
present ;  numerous  adhesions  around  the  ducts  separated. 

After -History. — Cured. 


35o    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stone  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 
Cholecystenterostomy . 

Case  156. — Mr.  O.,  aged  fifty-two,  seen  at  the  infirmary. 
Spasms  for  ten  months ;  jaundice  and  infective  cholangitis 
present. 

Operation. — 1/11/1896.  Cholecystenterostomy;  large  stone  too 
hard  to  crush,  and  patient  too  ill  to  bear  a  prolonged  operation. 
Liver  found  nodular  ;  Murphy's  button  used. 

After-History. — Complete  recovery,  and  jaundice  had  disappeared 
before  he  left  the  infirmary. 

Jaundice,  Chronic  Catarrhal  Cholangitis,  Hydatid  Disease  :  Hepa- 
totomy  and  Cholecystotomy. 

Case  157.— Mr.  M.,  aged  forty-four,  seen  at  the  infirmary. 
Jaundice  and  pain  ;  attacks  like  gall-stone  seizures. 

Operation. — 18/12/1896.  Hepatotomy  and  cholecystotomy; 
chronic  catarrh  of  the  bile-ducts  due  to  hydatid  disease ;  hydatid 
cyst  removed  from  the  liver ;  drainage. 

After-History. — Good  recovery;  jaundice  gradually  disappeared. 

Gall-stones  in  Common  Duct :  Choledochotomy ;  Cholecystotomy. 

Case  158. — Mrs.  W.,  aged  fifty,  seen  at  the  infirmary.  Attacks 
of  pain  for  some  time ;  loss  of  weight ;  jaundice  present. 

Operation. — 8/12/1896.  Cholecystotomy  and  choledochotomy  ; 
common  duct  incised,  two  stones  removed  ;  duct  sutured  and  gall- 
bladder drained. 

After-History. — Cured. 

Empyema  of  Gall-bladder,  Intervisceral  Fistula  ;  Drainage. 

Case  159. — Mr.  M.,  aged  sixty-five,  seen  with  Dr.  Selkirk, 
Boston  Spa.  Violent  pain ;  slightly  distended  gall-bladder ; 
greatly  dilated  stomach.  Rigors  and  fever  accompanied  the 
attacks  of  pain. 

Operation. — 1 7/1 2/1 896.  Exploration  and  drainage,  with  separa- 
tion of  adhesions.  No  gall-stones  found ;  extensive  adhesions  ; 
pyloric  stenosis.  The  gall-bladder  contained  dark,  thick,  grumous, 
purulent  material,  and  similar  contents  were  found  in  the  stomach, 
to  which  it  was  adherent. 

After-History. — Death  from  shock  thirty-six  hours  after  opera- 
tion. Unfortunately,  the  autopsy  could  not  be  made  until  forty- 
eight  hours  after  death,  when  decomposition  and  post-mortem 
digestion  had  softened  the  tissues  and  prevented  the  exact  nature 
of  the  disease  being  made  out.  The  question  of  previous  gall- 
bladder stomach  fistula  could  not  be  determined. 


APPENDIX 


35' 


Pain  and  Obstruction  :  Gall-bladder,  Stomach,  and  Colic  Adhesions 

separated. 

Case  160. — Mrs.  C,  aged  forty-two,  seen  with  Dr.  H.J.  Robson, 
Leeds.  Spasmodic  pain  resembling  gall-stones  ;  partial  intestinal 
obstruction. 

Operation. — 24/12/1896.  Exploratory,  with  separation  of  adhe- 
sions of  gall-bladder  to  stomach  and  colon  ;  no  gall-stones  found. 

After -History. — Recovery.  February,  1899,  reported  to  have 
had  no  pain  since  the  operation. 

Jaundice  and  Infective  Cholangitis,  Hydatid  Cyst  discharging  into  Bile- 
ducts  :  Hepatotomy  and  Cholecystotomy. 

Case  161. — Mr.  M.,  aged  forty-four,  seen  with  Dr.  Scatterty, 
Keighley.  Hydatid  disease,  six  years ;  simulating  gall-stone 
attacks,  one  year;  small  cysts  probably  discharging  into  bile- 
ducts  ;  infective  cholangitis  and  jaundice  present. 

Operation. — 28/1/1897.     Hepatotomy  and  cholecystotomy. 

After -History. — Good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  162. — Mrs.  H.,  aged  fifty-nine,  seen  with  Dr.  West, 
Morley.  Spasmodic  pain  for  years ;  jaundice  in  November ; 
cholangitis  with  rigors. 

Operation. — 15/1/1897.  Cholecystotomy;  removal  of  ten  large 
gall-stones  from  the  gall-bladder  ;  drainage. 

After-History. — Recovery  ;  the  patient  returned  home  in  three 
weeks,  and  looked  quite  ten  years  younger  than  before  the 
operation. 

Gall-stones  in  Common  Duct,  Jaundice  :  Cholecystotomy ;  Stones  worked 
back  through  Dilated  Cystic  Duct 

Case  163. — Mr.  B.,  aged  thirty-five,  seen  with  Dr.  Raimes, 
York.  Spasmodic  pain  for  fifteen  years  ;  jaundice  present  on 
several  occasions  ;  intense  pain  for  several  weeks. 

Operation. — 24/1/1897.  Cholecystotomy;  fourteen  gall-stones 
removed  from  the  cystic  and  common  ducts. 

After-History. — Good  recovery. 

Cancer  of  Liver  and  Gall-bladder  :  Exploratory. 

Case  164. — Mrs.  B.,  aged  fifty,  seen  with  Dr.  Williams,  Harro- 
gate.    Jaundice  present. 

Operation. — 22/1/1897.  Exploratory  ;  cancer  of  the  liver  and 
gall-bladder. 

After-History. — Recovered  from  the  operation,  but  not  materially 
relieved  ;  survived  for  three  months. 


352    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Cholecystitis  with  Catarrh  of  Ducts  :  Cholecystotomy. 

Case  165. — Mrs.  S.,  aged  thirty,  seen  at  the  infirmary.  Gall- 
stone symptoms  for  two  years ;  on  two  occasions  patient  was 
jaundiced,  and  gall-stones  were  found  in  the  motions ;  numerous 
attacks  of  pain  since  the  last  gall-stone  was  found  ;  slightly  dis- 
tended and  inflamed  gall-bladder. 

Operation. — 18/2/1897.  Cholecystotomy  ;  no  gall-stone  found; 
thickened  mucus  ;  chronic  catarrh  of  the  gall-bladder. 

After -History. — Good  recovery. 

Membranous  Cholecystitis  :  Separation  of  Adhesions  ;  Cholecystotomy. 

Case  166. — Mr.  C,  aged  thirty-six,  seen  with  Mr.  Jonathan 
Hutchinson  and  Dr.  Porter,  Helmsley.  Paroxysmal  pain  over 
the  upper  right  abdomen  for  twenty  years  ;  rigid  right  rectus ;  no 
tumour ;  membranous  casts  found  in  the  motions  for  some  time 
before  operation. 

Operation. — 1 8/2/1 897.  Laparotomy  and  separation  of  adhe- 
sions ;  no  gall  -  stones  found,  but  thick  membranous  mucus  ; 
cholecystotomy. 

After -History. — Smooth  recovery  and  no  recurrence  of  gall- 
bladder pain,  though  three  years  afterwards  had  membranous 
enteritis  again. 

Gall-stones  :  Cholecystotomy. 

Case  167. — Mrs.  G.,  aged  thirty-five,  seen  with  Dr.  Grant, 
Elgin.  Paroxysmal  pains  for  twelve  years,  usually  followed  by 
jaundice,  but  no  gall-stones  found  in  the  motions  ;  rigid  right 
rectus  ;  no  tumour. 

Operation. — 22/2/1897.  Cholecystotomy  ;  two  gall-stones  the 
size  of  cherries  removed,  one  from  the  gall-bladder  and  one  from 
the  cystic  duct. 

After-History. — Good  recovery  ;  well,  December,  1899. 

Chronic  Pancreatitis,  Jaundice  :  Cholccystenterostomy . 

Case  168. — Mr.  B.,  aged  thirty-four,  seen  with  Dr.  Dowsing, 
Hull.  Painful  attacks  resembling  cholelithiasis  since  June,  1896; 
deep  and  continuous  jaundice  since  December ;  distended  gall- 
bladder. 

Operation. — 25/2/1897.  Cholecystenterostomy  ;  no  gall-stones 
could  be  felt ;  numerous  adhesions ;  swelling  of  pancreas  ;  gall- 
bladder connected  to  the  duodenum  by  a  Murphy's  button  ;  cal- 
cium chloride  administered  before  operation  ;  chronic  pancreatitis. 

After-History. — Good  recovery. 


APPENDIX  353 

Gall-stones  :  Cholccystotomy. 

Case  169. — Mrs.  W.,  aged  forty,  seen  with  Dr.  Beesley,  Darton. 
Painful  indigestion  for  twenty  years ;  some  jaundice ;  severe 
cholelithic  pains  since  June,  1896;  usually  jaundiced  after  the 
attacks. 

Operation.  —  25/2/1897.  Cholecystotomy  ;  twenty  gall-stones 
removed  ;  empyema  of  the  gall-bladder,  with  adhesions  ;  calcium 
chloride  administered  before  the  operation. 

After-History. — Complete  recovery. 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Case  170. — Mrs.  B.,  aged  thirty-three,  seen  with  Dr.  Atkinson, 
Romaldkirk.  Painful  attacks  since  July,  1896,  following  on  a 
fall ;  tumour  in  the  gall-bladder  region. 

Operation. — 25/2/1897.  Cholecystotomy;  twenty-six  gall-stones 
removed  from  the  gall-bladder  and  the  cystic  duct,  with  some 
muco-pus. 

After -History. — Cured. 

Gall-stones  in  Common  Duct :  Choledochotomy. 

Case  171. — Mrs.  G.,  aged  thirty-eight,  seen  with  Dr.  Friend. 
Leeds.  Spasms  for  fifteen  years  ;  lately  the  attacks  had  been 
very  frequent,  and  followed  by  rigors  and  increased  jaundice  ;  no 
tumour. 

Operation. — 1 5/3/1897. — Choledochotomy;  fourteen  stones  re- 
moved from  the  gall-bladder  and  from  the  common  duct. 

After-History. — Good  recovery;  quite  well,  July,  1898. 

Cancer  of  Head  of  Pancreas  and  Common  Duct  :  Cholecystotomy. 

Case  172. — Mrs.  S.,  aged  sixty,  seen  with  Dr.  Nicholson, 
Gainsborough.  Patient  admitted  to  the  infirmary  with  con- 
tinuous pain  in  the  right  hypochondrium,  associated  with  dis- 
tended gall-bladder  and  some  oedema  of  the  legs  ;  jaundice  deep 
and  continuous. 

Operation. — 1 8/3/1 897.  Cholecystotomy  ;  cancer  of  head  of  the 
pancreas  and  common  duct. 

After-History. — Recovery. 

Gall-stones  in  Common  Duct,  Jaundice,  and  Infective  Cholangitis  : 

Cholecy  st  enter  ostomy . 

Case  173. — Mrs.  W.,  aged  fifty,  seen  with  Dr.  H.  J.  Robson, 
Leeds.  Spasms  for  years,  but  for  six  months  ague-like  attacks 
and  jaundice  associated  with  the  painful  seizure ;  no  tumour. 

Operation. — 6/4/1897.    Cholecystenterostomy  ;  adhesions  so  firm 

23 


354    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

that  the  common  duct  could  not  be  cleared,  though  gall-stones 
could  be  felt  in  it ;  small  gall-bladder  connected  to  the  duodenum 
by  Murphy's  button. 

After -History. — Good  recovery  ;  in  robust  health,  July  19,  1898. 

Gall-stones  :  Adhesions  :  Cholecystotomy  ;  Gastrolysis. 

Case  174. — Mrs.  A.  G.,  aged  thirty-three,  seen  with  Dr.  Hector, 
Drighlington.  Attacks  of  paroxysmal  pain,  varying  in  intensity 
in  right  hypochondrium,  since  the  age  of  eighteen.  Since  October 
last  the  attacks  had  been  followed  by  jaundice,  and  occasionally 
by  rigors  and  fever.  Pain  of  late  more  on  left  side  than  right ; 
she  had  lost  weight ;  no  tumour,  but  great  tenderness  felt  over 
the  region  of  the  gall-bladder. 

Operation. — 10/4/1897.  Cholecystotomy;  six  gall-stones  and 
some  inspissated  bile  removed ;  adhesions  to  pylorus  separated. 

After-History. — Complete  recovery. 

Gall-stones,  Tumour  of  Gall-bladder  :  Cholecystotomy. 

Case  175. — Mrs.  W.,  aged  thirty-six,  seen  with  Dr.  Lee, 
Dewsbury.  Spasms  occasionally  for  years  ;  two  attacks  of  severe 
abdominal  pain  in  December  and  February  last,  not  accom- 
panied by  vomiting  or  followed  by  jaundice ;  great  discomfort 
owing  to  the  presence  of  a  large  tumour  in  the  right  hypochon- 
drium. 

Operation. — 6/5/1897.  Cholecystotomy;  three  large  and  twenty 
small  gall-stones  removed  from  the  gall-bladder  ;  one  fair  sized, 
one  very  large,  and  three  small  ones  removed  from  the  cystic 
duct. 

After-History. — Complete  recovery. 

Gall-stones,  Phlegmonous  Cholecystitis  and  Gangrene  of  Gall-bladder  : 
Cholecystotomy,  and  Gauze  Packing. 

Case  176. — Mr.  H.,  aged  forty-seven,  seen  with  Dr.  Smith, 
Hyde  Park,  Leeds.  Spasms  for  years  ;  for  six  weeks  severe  pain 
with  swelling  below  the  right  costal  margin  ;  jaundice  first  noticed 
a  month  ago ;  had  had  several  ague-like  seizures,  and  during  the 
week  before  operation  was  acutely  ill  with  manifest  local  peri- 
tonitis. 

Operation.  [9/5/1897.  Cholecystotomy;  gall-bladder  dark  in 
colour  and  full  of  grumous  pus ;  one  or  two  greenish  gangrenous 
patches  on  it ;  nine  gall-stones  removed ;  adhesions  of  omentum 
not  disturbed ;  frae  drainage  and  exclusion  with  iodoform  gauze. 

After -History.    -Complete  recovery  ;  well,  1899. 


APPENDIX  355 

Gall-stone  in  Common  Duct,  Jaundice,  and  Infective  Cholangitis  : 

Choledochotomy. 

Cash  177.— Mrs.  G.,  aged  sixty-two, seen  with  J  )r.  Kershaw,  Pud- 
sey.  For  twenty  years  attacks  of  spasms,  but  no  jaundice  until  four 
weeks  before  operation,  since  which  time  jaundice  continuous,  with 
ague-like  attacks  and  rapid  loss  of  flesh  ;  patient  very  feeble. 

Operation. — 21/5/1897.  Choledochotomy;  one  gall-stone  the 
size  of  a  cherry  removed  from  the  common  duct  through  an 
incision,  which  was  afterwards  sutured  ;  drainage  of  the  peritoneal 
pouch. 

Aftev-Histovy. — Recovered  from  the  operation,  but  never  gained 
strength,  and  death  occurred  at  the  end  of  five  weeks  from  ex- 
haustion. 

Obstruction  in  Common  Duct,  Gall-stones  with  Cancer  (?)  Suppurative 

Cholangitis  :  Cliolccy st enter ost omy . 

Case  178. — Mrs.  S.,  aged  sixty-five,  seen  with  Dr.  Thompson, 
Skipton.  Indefinite  history  of  past  pains  ;  influenza  followed  by 
deep  jaundice  twelve  weeks  before  ;  the  pain  did  not  precede  the 
jaundice  ;  rapid  loss  of  flesh  and  repeated  rigors,  with  temperature 
1040  and  1050  ;  uniform  enlargement  of  the  liver  ;  petechias  in  the 
.skin  ;  epistaxis.     Diagnosis  :  suppurative  cholangitis. 

Operation. — 25/5/1897.  Patient  too  ill  for  prolonged  operation  ; 
cholecystenterostomy  by  Murphy's  button  ;  thickening  of  common 
duct  felt,  with  gall-stones  (growth  ?)  ;  pus  and  bile  in  ducts. 

After -History. — Death  from  exhaustion  and  shock  the  third  day. 

Gall-stones  in  Common  Duct :  Cholecystotomy  and  Cholelithotrity. 

Case  179. — Mrs.  N.,  aged  fifty-nine,  seen  with  Dr.  Panton, 
Bolton.  Gall-stones.  First  attack  fourteen  years  ago  ;  three  or 
four  attacks  the  following  year,  then  an  interval  of  six  years.  For 
last  six  weeks  patient  had  never  been  free  ;  sometimes  two  to  four 
attacks  daily.  Rigors,  vomiting,  and  jaundice  had  characterized 
each  attack  ;  tumour  present. 

Operation. — 27/5/1897.  Cholecystotomy;  removal  of  gall-stones- 
from  the  gall-bladder,  cystic,  hepatic,  and  common  ducts  ;  chole- 
lithotrity performed  on  those  stones  which  could  not  be  removed 
through  the  gall-bladder  incision.  Subsequent  injections  of  olive 
oil  were  employed  to  dissolve  any  fragments  remaining  in  the 
common  duct. 

After-History. — Good  recovery. 

Gall-stones  in  Common  Duct :  Cholecystotomy,  etc. 
Case  180. — Mrs.  C,  aged  fifty-eight,  seen  with  Dr.  Ramsay, 
York.     Gall-stone   attacks  without  jaundice    for    several    years ; 

23—2 


356   DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

attacks  very  frequent  of  late,  and  slight  jaundice  following 
seizures  ;  chill  and  fever  after  some  of  the  attacks. 

Operation. —  1 2/6/1 897.  Cholecystotomy  ;  seventy  gall-stones 
removed  from  gall-bladder  and  the  cystic  duct,  and  some 
passed  back  from  the  common  duct  into  the  gall-bladder,  and  then 
removed ;  drainage. 

Aftev-Histovy. — Complete  and  permanent  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  181. — Mrs.  R.,  aged  thirty-eight,  seen  with  Dr.  Empey, 
Cross  Hills.  First  attack  of  abdominal  pain  fourteen  years  ago, 
recurring  at  intervals  of  three  months  to  one  year.  For  five  days 
following  and  including  Good  Friday  the  patient  had  had  one 
attack  daily ;  then  another  at  Whitsuntide ;  none  since.  The 
attacks  were  accompanied  by  rigors  and  vomiting,  and  followed 
by  jaundice  ;  patient  passed  four  small  stones  per  anum  after  the 
last  attack. 

Operation. — 17/6/1897.  Cholecystotomy;  many  stones  removed, 
one  as  large  as  a  pigeon's  egg. 

After-History. — Complete  recovery. 

Gall-stones  in  Ampulla  of  Vater  :  Duodeno-Choledochotomy. 

Case  182. — Mrs.  B.,  aged  thirty-nine,  seen  at  the  infirmary. 
First  attack  of  pain  in  February,  with  jaundice,  clay-coloured 
motions,  and  dark-coloured  urine,  also  vomiting  and  constipation  ; 
confined  to  bed  five  weeks ;  second  attack  one  month  ago,  similar 
to  the  first ;  no  tumour  to  be  felt. 

Operation. — 1 7/6/1897.  Duodeno-choledochotomy;  gall-bladder 
found  to  be  much  atrophied ;  no  stones  in  either  gall-bladder  or 
ducts,  but  two  small,  hard  stones  felt  and  removed  from  the  ampulla 
of  Yater  through  an  incision  in  the  duodenum,  which  was  then 
sutured  ;  no  drainage. 

After-History. — Complete  recovery  ;  well  when  seen  six  months 
after. 

Gall-stones,  Jaundice,  Cancer  of  Common  and  Cystic  Duct : 
Cholecystotomy. 

Case  183.— Mrs.  G.,  aged  fifty-three,  seen  with  Dr.  Clarke, 
Morley.  Spasms  for  eighteen  years;  for  a  year  severe  pain, 
failure  of  health, and  loss  of  weight ;  jaundice  and  ague-like  attacks 
for  a  month  ;  no  tumour. 

Operation. — 28/6/1897.  A  number  of  gall-stones  removed,  but 
cancer  of  the  junction  of  the  cystic  and  common  ducts,  with  a 
cancerous  nodule  in  the  liver,  found  ;  drainage  of  the  gall-bladder. 

After -History. — Recovery  ;  decided  relief  for  a  time,  and  patient 
returned  home  within  the  month. 


APPENDIX 


357 


Jaundice,  Cirrhosis  of  Liver,  Hemorrhagic  Diathesis:  Laparotomy. 

Case  184. — Mrs.  H.,  aged  fifty-four,  seen  with  Dr  Ellis, 
Halifax.  Patient  had  suffered  from  spasms  since  the  age  of 
seventeen  ;  they  had  lately  increased  in  number  and  severity,  and 
were  accompanied  by  vomiting  and  followed  by  jaundice. 

Operation. — 15/7/1897.  Exploratory;  liver  found  nodular  and 
much  contracted  (cirrhosis)  ;  gall-bladder  contracted  over  several 
stones,  but  the  ducts  were  free ;  wound  closed  without  further 
interference  as  the  bleeding  was  very  free,  and  the  patient  was 
bearing  the  operation  very  badly. 

After -History. — Decided  relief;  wound  healed  by  first  intention, 
and  the  patient  returned  home  in  the  third  week. 

Gall-stones,  Cancer  of  Stomach  :  Cholecystotomy. 

Case  185.— Mrs.  M.,aged  fifty,  seen  at  the  infirmary.  Attacks 
of  abdominal  pain  since  the  age  of  fifteen  ;  first  attack  due  to  gall- 
stones last  August,  when  patient  was  confined  to  bed  for  twelve 
weeks  ;  she  had  had  rigors,  vomiting,  and  jaundice  ;  second  attack 
in  February  ;  in  bed  five  weeks  ;  urine  high-coloured,  motions  pale. 
On  examination  great  tenderness  could  be  felt. 

Operation. — 1 6/7/1 897.  Cholecystotomy  ;  gall-bladder  found 
full  of  stones — seventy-six  removed  ;  very  extensive  adhesions  in 
all  directions  were  found  ;  there  was  a  malignant  growth  involving 
the  pylorus. 

After-History. — Good  recovery  from  the  operation,  and  marked 
relief  to  symptoms. 

Gall-stones,  Cholecystitis :  Cholecystotomy. 

Case  186. — Mrs.  P.,  aged  thirty-eight,  seen  with  Dr.  Panton, 
Bolton.  Biliary  colic  at  irregular  intervals  for  nine  years  ;  jaun- 
dice had  followed  recent  attacks,  and  during  the  month  previous 
to  operation  there  had  been  attacks  of  fever  with  the  seizures,  the 
temperature  reaching  104°;  loss  of  weight  16  pounds  in  the  month  ; 
enlarged  right  lobe  of  the  liver  felt,  with  tenderness  over  the  gall- 
bladder. 

Operation. — 21/7/1897.  Cholecystotomy  ;  small  gall-bladder 
containing  muco-pus  and  two  gall-stones,  which  were  removed  ; 
drainage  ;  adhesions  extensive. 

After- History. — Good  recovery  ;  quite  well  in  1898. 

Gall-stones  in  Common  Duct :  Choledochotomy  and  Cholecystotomy. 

Case  187. — Mrs.  A.,  aged  forty-two,  seen  at  the  infirmary. 
Gall-stones ;  first  attack  of  pain  six  years  ago  ;  frequent  attacks 
since,  increasing  in  severity,  with  rigors,  vomiting,  and  jaundice ; 
urine  dark-coloured  and  faeces  very  light ;  no  tumour. 


358    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

Operation. — 28/7/1897.     Choledochotomy  ;  one  large  and  several 
small  stones  removed  from  the  gall-bladder  and  common  duct. 
A  fter-History. — Good  recovery. 

Gall-stones  in  Common  Duct  :  Choledochotomy. 

Case  188. — Mrs.  R.,  aged  fifty-one,  seen  with  Dr.  Jones,  Huck- 
nall  Torkard.  Subject  to  attacks  of  pain  over  the  liver  for  years 
up  to  three  years  ago,  since  which  time  to  Christmas,  1897,  nac^ 
been  free  from  pain  ;  from  Christmas  numerous  attacks,  usually 
followed  by  jaundice  and  ague-like  seizures ;  great  loss  of  flesh ; 
presystolic  cardiac  bruit. 

Operation. — 5/8/1897.  Choledochotomy;  large  gall-stone  removed 
through  an  incision  in  the  common  duct,  which  was  then  closed 
by  sutures. 

After-History. — Good  recovery  ;  quite  well  when  heard  of  some 
months  later  ;  in  good  health,  1900. 

Gall-stones  :  Cholecystotomy. 

Case  189. — Mrs.  H.,  aged  fifty-four,  seen  with  Dr.  Alcock, 
Goole,  and  Dr.  Churton,  Leeds.  Subject  to  gall-stone  attacks,  at 
times  followed  by  jaundice,  for  four  years  ;  loss  of  flesh  ;  pain  often 
on  left  side ;  enlarged  right  lobe  of  the  liver,  with  enlargement  of 
the  gall-bladder  ;  spleen  felt  well  below  the  left  costal  margin,  but 
blood  normal. 

Operation. — 30/8/1897.  Cholecystotomy;  numerous  gall-stones 
removed  from  the  gall-bladder  and  cystic  duct  ;  drainage  of  the 
gall-bladder. 

A  fter-History. — Good  recovery  from  the  operation,  and  returned 
home  within  the  month  ;  no  recurrence  of  gall-stones  ;  the  follow- 
ing year  developed  phthisis  after  pneumonia. 

Gall-stones,  Infective  Cholangitis,  Empyema  of  Gall-bladder  : 

Cholecystotomy. 

Case  190. — Mr.  S.,  aged  forty,  seen  with  Dr.  Sprent,  Slingsby. 
Acute  suppurative  cholangitis.  First  attack  of  pain  four  years 
ago,  repeated  frequently  since  at  varying  intervals,  ranging  from 
one  to  twelve  months.  Lately  they  had  been  very  frequent, 
sometimes  three  attacks  a  week.  Patient  had  rigors,  dark-coloured 
urine,  light  motions,  and  jaundice.  Enlarged  gall-bladder  easily 
felt  through  abdominal  parietes. 

Operation. — 2/9/1897.  Cholecystotomy  ;  1  ounce  of  pus  removed 
from  the  gall-bladder  ;  also  two  large  gall-stones  removed  from 
the  cystic  duct,  which  was  ulcerated. 

After-History.— Complete  recovery  of  health,  but  at  times  had  a 
discharge  from  the  scar  where  the  drainage-tube  had  been. 


APPENDIX  359 

Gall-stones  :  Cholecystotomy. 

Case  191. — Mrs.  T.,  aged  thirty-five,  seen  at  the  infirmary. 
Gall-stones ;  recurring  attacks  of  paroxysmal  pain  in  right  hypo- 
chondrium,  with  vomiting  and  slight  rigors;  no  jaundice  during 
paroxysms,  but  for  a  few  hours  after,  a  tumour  could  be  distinctly 
felt,  and  then  disappeared. 

Opevation. — 23/9/1897.  Cholecystotomy  ;  two  gall-stones  re- 
moved. 

After-History. — Complete  recovery. 

Catarrhal  Cholecystitis :  Cholecystotomy. 

Case  192. — Mr.  B.,  aged  forty-six,  seen  with  Dr.  John  Clarke, 
Morley.  Patient  had  had  recurrent  attacks  of  pain,  resembling 
in  every  way  the  attacks  due  to  gall-stones,  and  also  followed  by 
jaundice. 

Opevation. — 23/9/1897.  Cholecystotomy;  no  gall-stones  found, 
but  thickened  mucus  in  the  gall-bladder ;  chronic  catarrh  ;  drain- 
age of  the  gall-bladder  for  a  fortnight. 

After-History. — Complete  and  permanent  recovery. 

Gall-stones,  Hydrops  of  Gall-bladder  :  Cholecystotomy. 

Case  193. — Mrs.  G.,  aged  fifty,  seen  with  Dr.  Woods,  Batley 
Spasms  for  years  ;  swelling  on  right  of  abdomen  noticed  for  four 
years  ;  no  jaundice  ;  tumour  of  gall-bladder  could  be  distinctly  felt. 

Operation. — 28/9/1897.  Cholecystotomy  ;  twenty-two  gall-stones 
removed  from  the  gall-bladder  and  cystic  duct,  and  half  a  pint  of 
mucus  from  the  gall-bladder. 

After-History. — Good  recovery  ;  quite  well  some  months  later. 

Gall-stone,  Empyema  of  Gall-bladder,  Phlegmonous  Cholecystitis  : 
Choledochotomy ;  Cholecystotomy. 

Case  194. — Mrs.  B.,  aged  thirty,  seen  with  Dr.  Greenwood, 
Ossett.  Gall-stones ;  attacks  of  paroxysmal  pain  in  gall-bladder 
region  for  five  years ;  the  first  attack  was  accompanied  by  rigors, 
vomiting,  and  nausea,  and  followed  by  jaundice  ;  it  lasted  six 
weeks.  Since  January  1,  1893,  patient  had  always  been  jaundiced 
and  unable  to  work,  and  had  had  amenorrhcea  extending  over  long 
periods ;  lately  metrorrhagia  ;  no  tumour  could  be  felt. 

Operation. — 7/10/1897.  Choledochotomy;  one  stone,  weighing 
1  drachm,  removed  from  common  duct;  offensive  pus  drained  from 
the  gall-bladder,  which  was  dark  coloured  and  covered  wTith  lymph. 

After-History. — Good  recovery. 

Chronic  Pancreatitis,  Gall-stones,  Contracted  Bile-duct,  Jaundice  : 
Cholecystcnterostomy  ;  Gastrolysis. 

Case  195.— Mrs.  R., aged  forty-nine,  seen  with  Dr.  Kilner  Clarke, 
Huddersfield.     Patient  bad  had  two  gall-stones  removed  from  the 


360   DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

gall-bladder  in  Canada  three  years  ago,  but  the  ducts  could  not  be 
cleared  on  account  of  collapsed  condition  ;  never  free  from  jaundice 
since  operation  ;  frequent  vomiting  ;  dilatation  of  stomach  ;  tender- 
ness over  the  gall-bladder  and  pylorus. 

Operation. — 18/10/1897.  Cholecystenterostomy  ;  adhesions  of 
gall-bladder,  bowel,  and  pylorus  very  firm,  but  freely  detached 
thickening  along  the  bile-ducts,  evidently  obstructing  flow  of  bile  ; 
gall-bladder  united  to  duodenum  by  metal  button.  Pancreas 
swollen. 

After-History. — Slow  but  satisfactory  recovery  ;  health  gradually 
regained. 

Gall-stones  in  Gall-bladder  and  Common  Duct :  Chole cystotomy  ; 

Cholelithotrity. 

Case  196. — Mrs.  B.,  aged  fifty-one,  seen  with  Dr.  Moffatt, 
Keighley.  Gall-stones ;  first  attack  four  years  ago,  very  severe  ; 
relieved  after  several  hours  by  hypodermic  injections  of  morphia  ; 
it  was  accompanied  by  rigors  and  vomiting,  but  no  jaundice 
followed  ;  frequent  attacks  since,  followed  by  slight  jaundice  ;  no 
tumour  could  be  felt. 

Operation. — 19/10/1897.  Cholecystotomy  ;  removal  of  several 
gall-stones  from  the  gall-bladder  and  cystic  duct,  and  others 
crushed  in  common  duct. 

After-History. — Good  recovery. 

Gall-stones :  Cholecystotomy. 

Case  197.-  -Mrs.  W.,  aged  forty-two,  seen  at  the  infirmary. 
Gall-stones ;  recurring  attacks  of  pain  in  right  hypochondrium, 
three  years,  accompanied  by  severe  vomiting,  retching,  and  rigors  ; 
no  jaundice  ;  tumour  present. 

Operation. — 20/10/1897.     Cholecystotomy. 

After-History. — Good  recovery. 

Catarrhal  Cholecystitis,  Adhesions  :  Cholecystotomy  and  Gastrolysis. 

Case  198. — Mr.  C,  aged  thirty-three,  seen  with  Dr.  Squance, 
Sunderland.  Subject  to  attacks  of  gall-stone  colic  from  1880; 
severe  attack  in  1886,  followed  by  jaundice  for  a  fortnight ;  lately 
the  attacks  had  recurred  every  week,  but  without  jaundice  ;  some 
tenderness  over  gall-bladder. 

Operation. — 8/11/1897.  Cholecystotomy;  chronic  catarrh  of 
the  gall-bladder  ;  no  gall-stones  found  ;  drainage  of  the  gall-bladder 
and  detaching  of  adhesions  to  pylorus,  etc. 

After- History. — Complete  recovery;  there  had  been  no  recurrence 
of  pain  six  months  later;  well,  [902. 


APPENDIX  3r" 

Tvplwidal  Cholecystitis,  Intestinal  Obstruction  by  Band :  Division  of 

Hand. 

Cask  199. — Mrs.  S.,  aged  thirty-six,  seen  with  Dr.  Crawford, 
Ingrow.  Typhoidal  cholecystitis  in  March  and  April,  1897; 
intestinal  obstruction,  November,  1897. 

Operation. — 18/11/1897.  Laparotomy;  division  of  band  stretch- 
ing from  liver  to  colon  and  omentum,  and  compressing  hepatic 
flexure  of  colon. 

After-History.  — Complete  recovery. 

Gall-stone,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Case  200. — Mrs.  W.,  aged  thirty-six,  seen  with  Dr.  Barrs  and 
Dr.  Rumboll,  Leeds.  Pain  on  right  of  abdomen,  with  tumour 
simulating  movable  kidney ;  never  had  spasms. 

Operation. — 25/11/1897.  Cholecystotomy;  10  ounces  of  pus 
removed  from  the  gall-bladder,  and  a  gall-stone  the  size  of  a  cherry 
removed  from  the  cystic  duct ;  drainage. 

After- History. — Returned  home  within  a  month  with  wound 
healed.  Health  regained.  Three  years  later  had  retention  of 
mucus  in  gall-bladder  requiring  drainage. 

Gall-stones,  Cancer  of  Liver  and  Gall-bladder  :  Cholecystectomy  and 

Hepatectomy. 

Case  201. — Mrs.  H.,  aged  fifty-two,  seen  with  Dr.  Ruxton, 
Blackpool.  Pain  over  the  gall-bladder  for  a  year ;  tumour 
noticed  for  a  month. 

Operation. — 27/11/1897.  Cholecystectomy  and  hepatectomy  ; 
cancer  of  the  gall-bladder  and  adjoining  part  of  the  liver,  with 
gall-stones  in  the  gall-bladder  and  cystic  duct.  All  affected  parts 
removed  by  means  of  an  elastic  ligature. 

After -History. — Good  recovery  ;  patient  out  of  doors  in  six 
weeks  ;  recurrence  of  disease  in  April,  1898. 

Chronic  Catarrhal  Cholecystitis  :  Cholecystotomy. 

Case  202. —Mrs.  F.,  aged  forty-six,  seen  with  Dr.  Smyth, 
Keighley.  Gall-stones  ;  patient  operated  on  in  March,  1896,  in  a 
neighbouring  hospital,  but  is  said  to  have  derived  little  benefit. 
The  operation  was  only  exploratory  for  symptoms  pointing  to 
renal  calculus,  but  nothing  was  discovered.  Was  an  in-patient  in 
March,  1897,  an^  transferred  to  Dr.  Churton.  Slight  improve- 
ment under  medical  treatment.  Since  May  the  attacks  had 
grown  in  severity  and  frequency.     No  jaundice. 

Operation. — 17/12/1897.  Ropy  mucus  removed  from  the  gall- 
bladder, which  was  seat  of  chronic  catarrh  ;  no  stones  were  found  ; 
drainage. 

After-History. — Good  recovery  and  marked  relief  to  symptoms 


362    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Case  203. — Mrs.  B.,  aged  forty,  seen  with  Dr.  Atkinson.  Gall- 
stones. Patient  had  suffered  for  nine  years  from  typical  attacks, 
due  to  presence  of  stones  in  the  gall-bladder ;  attacks  followed  by 
jaundice,  and  by  constipation  alternating  with  diarrhoea.  For  the 
last  twelve  months  she  had  been  confined  to  bed.  Tumour  easily 
denned. 

Operation. — 23/12/1897.  Cholecystotomy  ;  fifty-six  gall-stones 
removed  from  the  gall-bladder,  and  about  half  a  pint  of  muco-pus; 
drainage. 

After-History. — Good  recovery. 

Catarrh  of  Gall-bladder,  with  Retention  of  Ropy  Mucus  :  Chole- 

cy stent er ostomy. 

Case  204. — Mrs.  S.,aged  twenty-seven,  seen  with  Dr.  Patterson, 
Dalton-in-Furness.  Recurrence  of  pain  exactly  resembling  gall- 
stone attacks,  but  without  jaundice  ;  confined  about  a  month  ago, 
but  attacks  no  better  since  delivery,  and  larger  doses  of  morphia 
required. 

Operation.  —  7/1/1898.  Cholecystenterostomy  ;  adhesions  de- 
tached and  gall-bladder  and  ducts  explored  ;  no  gall-stones  found, 
but  thickened  ropy  mucus  in  gall-bladder ;  gall-bladder  connected 
to  duodenum  by  metal  button. 

After-History. — Good  recovery,  and  returned  home  within  a 
month ;  some  pain  a  few  weeks  after  return  ;  quite  well  at  the 
beginning  of  1899. 

Catarrh  of  Gall-bladder,  Adhesions  to  Pylorus  :  Cholecystotomy  ; 

Gastrolysis. 

Case  205. — Mr.  W.,  aged  twenty-three,  seen  with  Dr.  Snell, 
Gargrave.  In  May,  1890,  patient  was  in  the  infirmary,  when 
adhesions  of  the  pylorus  to  the  gall-bladder  were  broken  down. 
He  was  readmitted  in  1892  in  consequence  of  a  return  of  previous 
pain,  and  taught  to  wash  out  his  stomach,  which  afforded  him 
relief.  For  past  twelve  months  pain  had  increased  in  severity, 
and  was  localized  to  the  old  wound.  There  had  been  no  jaundice  ; 
he  had  lost  weight  rapidly  during  the  last  three  weeks. 

Operation.  —  7/1/1898.  Cholecystotomy  for  chronic  catarrh; 
firm  adhesions  were  found  between  the  pylorus  and  under-surface 
of  gall-bladder  ;  the  adhesions  were  broken  down  and  omentum 
interposed. 

After-History. — Complete  recovery  and  loss  of  all  pain ;  June, 
1899,  the  patient  was  quite  well  and  had  regained  flesh  ;  later,  had 
some  stomach  symptoms. 


APPENDIX  363 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholc cystotomy. 

Case  206. — Mrs.  D.,  aged  fifty-one,  seen  at  the  infirmary. 
Gall-stones ;  recurring  attacks  of  pain  since  the  age  of  eighteen 
years,  accompanied  by  rigors,  but  no  jaundice.  Tumour  observ- 
able by  patient  since  August,  1897. 

Operation. — 20/1/1898.  Cholecystotomy  ;  gall-bladder  aspirated 
and  \  ounce  of  pus  drawn  off;  209  gall-stones  removed  from 
the  gall-bladder  and  ducts  ;  drainage. 

After-History. — Good  recovery  ;  well  when  last  heard  of. 

Gall-stones  :  Cholecystotomy  ;   Vertical  Displacement  of  Liver. 

Case  207. — Mrs.  W.,  aged  forty-four,  seen  with  Dr.  Allott, 
Barnsley.  Gall-stones.  For  five  years  the  patient  had  suffered 
from  recurring  attacks  of  paroxysmal  pain  in  the  region  of  the 
gall-bladder,  lasting  several  hours  and  confining  her  to  bed  for 
some  time  afterwards.  The  pain  was  accompanied  and  followed 
by  all  the  usual  symptoms  on  each  occasion  ;  no  tumour  present. 

Operation. — 27/1/1898.  Cholecystotomy  ;  a  stone  the  size  of  a 
cherry  found  in  the  cystic  duct,  crushed  by  the  fingers  and 
extracted  through  the  cholecystotomy  opening ;  gall-bladder  con- 
tracted and  surrounded  by  adhesions  ;  right  lobe  of  liver  abnormal 
in  shape  and  position  ;  vertical  displacement  of  liver. 

After-History. — Good  recovery,  and  well  when  last  seen. 

Gall-stones,  Cancer  of  Gall-bladder  and  Liver  :  Cholecystectomy  and 

Hepatectomy. 

Case  208. — Mrs.  B.,aged  fifty-two,  seen  with  Dr.  Carter,  Rich- 
mond. Attacks  of  pain  in  right  hypochondrium  commenced  in 
September,  1897,  Du^  became  especially  severe  in  December; 
a  large  tumour  present. 

Operation.  — 17/2/1898.  Cholecystectomy  and  hepatectomy; 
gall-bladder  and  cystic  duct  filled  with  stones  ;  walls  of  gall- 
bladder infiltrated  with  growth,  wThich  extended  into  the  liver, 
pylorus,  and  colon;  adhesions  detached;  gall-bladder  and  adjoining 
part  of  liver  removed  by  elastic  tourniquet ;  tumour  of  colon 
removed  at  same  time. 

After-History. — Death  from  shock. 

Gall-stone  in  Common  Duct,  Jaundice,  and  Infective  Cholangitis  : 
Duodeno-Choledochotomy. 

Case  209. — Mrs.  H.,  aged  fifty-seven,  seen  with  Dr.  Parke, 
Tidswell.  Gall-stones ;  first  attack  twelve  months  ago,  lasting 
for    several    hours,   followed    by   jaundice.     It    commenced  with 


364    DISEASES  OE  THE  GALL-BLADDER  AND  BILE-DUCTS 

a  rigor ;  the  urine  was  very  dark-coloured  and  the  motions  pale  ; 
the  attacks  had  recurred  since  at  very  short  intervals  ;  she  had 
lost  considerably  in  weight ;  infective  cholangitis. 

Operation. — 3/3/1898.  Duodeno-choledochotomy  ;  very  exten- 
sive adhesions  were  met  with  and  broken  down ;  gall-bladder  not 
to  be  found  ;  a  large  stone  was  found  in  the  ampulla  of  Vater, 
and  removed  through  an  incision  in  the  duodenum;  duodenum 
sutured ;  no  drainage. 

After-History. — Good  recovery  ;  report  later  to  say  the  patient 
was  quite  well. 

Gall-stones :  Cholecystotomy. 

Case  210. — Miss  H.,  aged  fifty,  seen  with  Dr.  Haydon,  Marl- 
borough, Wilts.  Attacks  of  pain  over  the  gall-bladder  off  and 
on  for  seventeen  years;  frequent  since  Christmas,  1897;  no 
jaundice. 

Operation. — 11/3/1898.  Cholecystotomy;  eight  gall-stones  re- 
moved from  the  gall-bladder  and  cystic  duct ;  drainage  of  the 
gall-bladder. 

After -History. — Good  recovery  ;  quite  well  when  last  heard  of. 

Gall-stones,  Adhesion  to  Pylorus  :  Cholecystotomy  ;  Gastrolysis. 

Case  211. — Mr.  H.,  aged  forty-five,  seen  with  Dr.  Hyne,  Corn- 
wall, and  Dr.  Barrs,  Leeds.  Hepatic  colic  and  dyspepsia  for  ten 
years ;  of  late  the  attacks  had  been  frequent ;  loss  of  flesh ;  no 
jaundice  present. 

Operation. — 12/3/1898.  Cholecystotomy;  350  gall-stones  re- 
moved from  the  gall-bladder  and  cystic  duct :  adhesions  to  pylorus 
and  gut  separated. 

After- LI i story. — Good  recovery  ;  quite  well,  June,  1903. 

Gall-stones,  Acute  Cholecystitis  with  Peri-Cholecystitis  and  Abscess  : 

Cholecystotomy. 

Case  212. — Mr.  F.,  aged  forty-eight,  seen  with  Dr.  Hick, 
Leeds.  Painful  epigastric  attacks  for  years,  followed  by  vomiting, 
but  without  jaundice  ;  acute  symptoms  about  a  week  ;  increasing 
swelling  under  right  ribs;  acute  cholecystitis,  with  abscess  and 
gall-stones. 

Operation. — 19/3/1S98.  Cholecystotomy;  gall-bladder  had  rup- 
tured, and  there  was  an  abscess  outside  it  limited  by  adhesions  ; 
twelve  gall-stones  removed  ;  drainage  of  the  gall-bladder. 

After-History. — Good  recovery  ;  perfectly  well  when  seen  four 
months  later. 


APPENDIX  365 

Chronic  Pancreatitis  :  Cholecystotomy. 

Cask  213.— Mr.  D.,  aged  forty-five,  seen  with  Dr.  Robertson, 
Pickering.  Painful  epigastric  attacks  twelve  months,  with 
vomiting,  but  no  jaundice;  deep  jaundice  since  January  1,  with 
ague-like  attacks;  loss  of  2 \  stones  in  weight. 

Operation. — 29/3/1898.  Cholecystotomy;  drainage  of  distended 
gall-bladder;  thickened  duct  felt  and  swelling  of  pancreas,  thought 
to  be  cancer  of  head  of  pancreas  and  common  bile-duct  ;  drainage 
of  gall-bladder  for  ten  days. 

After-History.  —  Complete  recovery;  quite  well,  August  16, 
1898 — had  gained  1  stone  in  weight ;  in  good  health,  1901.  Case, 
chronic  pancreatitis. 

Gall-stones  in  Gall-bladder  and  Common  Duct,  Jaundice,  and  Infective 
Cholangitis  :  Cholecystotomy  and  Cholelithotrity. 

Case  214. — Mrs.  N.,  aged  fifty-nine,  seen  with  Dr.  Erskine 
Stuart,  Batley.  Gall-stones ;  first  attack  fourteen  years  ago ; 
pain  paroxysmal  in  character,  and  at  first  was  short  in  duration, 
recurring  about  every  two  months,  but  for  a  short  time  previous 
to  admission  came  on  every  fourteen  days,  was  much  more  severe, 
and  lasted  for  a  longer  time.  Patient  had  vomited,  and  had  had 
severe  rigors,  and  each  attack  was  followed  by  jaundice.  No 
tumour  to  be  felt. 

Operation. — 31/3/1898.  Cholecystotomy;  gall-bladder  aspirated 
previous  to  opening  ;  565  gall-stones  removed,  several  crushed  in 
ducts  ;  firm  adhesions  around  the  gall-bladder. 

After-History. — Good  recovery. 


Gall-stones  in  Common  Duct :  Choledochotomy. 

Case  215. — Mrs.  S.,  aged  forty-seven,  seen  with  Dr.  Saunders, 
Wales.  Patient  first  admitted  in  February,  when  she  refused 
operation.  The  history  was  that  eighteen  months  previous  to 
admission  she  had  a  severe  attack  of  abdominal  pain  in  the  right 
hypochondrium,  which  radiated  to  the  back  and  the  left  shoulder- 
blade.  The  attacks  had  recurred  frequently  since,  and  had 
increased  in  severity  and  duration.  Membranous  casts  noticed  in 
the  motions;  a  tumour,  the  size  of  an  egg,  felt  on  palpation. 

Operation. — 7/4/1898.  Choledochotomy;  seventy-eight  stones 
removed  from  the  gall-bladder,  cystic  and  common  ducts  ;  numer- 
ous adhesions  detached. 

After-History. — Recovery ;  left  the  infirmary  well  within  the 
month  with  the  wound  healed ;  subsequently  a  fistula  formed. 


366    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Catarrhal  Cholecystitis  :  Cholecystotomy. 

Case  216. — E.  G.,  female,  aged  thirty-two,  seen  with  Dr. 
Davidson,  Drighlington.  First  attack,  September,  1897,  on 
leaving  her  bed  after  an  attack  of  rheumatic  fever.  The  attacks 
had  recurred  frequently  since,  and  had  increased  in  violence ; 
they  were  always  followed  by  jaundice.  No  tumour  could  be  made 
out. 

Operation. — 7/4/1898.  Gall-bladder  aspirated,  and  on  incision 
found  full  of  thick,  bile-stained  fluid  containing  soft,  sago-like  bodies ; 
no  stones  found  ;  drainage. 

After-History. — Good  recovery  ;  no  recurrence  of  pain. 

Gall-stones  in  Hepatic  and  Common  Ducts  :  Choledochotomy ;  Gastrolysis. 

Case  217. — Mrs.  J.,  aged  forty-nine,  seen  with  Dr.  Irving, 
Huddersfield.  Seven  years  ago  frequent  attacks  of  spasms  for  a 
year,  after  which  no  recurrence  for  six  years.  January,  1898, 
recurrence  of  pain  followed  by  jaundice  and  ague-like  seizures  ; 
stomach  dilated  and  liver  enlarged. 

Operation. — 16/5/1898.  Choledochotomy;  adhesions  of  gall- 
bladder to  pylorus  separated ;  gall-bladder  drained ;  common 
duct  incised  and  several  gall-stones  removed ;  finger  inserted  into 
duct,  and  other  stones  felt  in  hepatic  duct  and  removed  by  small 
scoop. 

After-History. — Complete  recovery  and  regained  health. 

Gall-stone  in  Common  Duct :  Duodeno -choledochotomy . 

Case  218. — Mr.  G.,  aged  thirty-nine,  seen  with  Dr.  Peach 
Hay,  Peterborough.  Gall-stones  ;  first  attack  six  and  a  half  years 
ago  ;  pain  more  or  less  continuous  since,  and  occasionally  severe 
paroxysmal  attacks  lasting  twelve  to  thirteen  hours  ;  the  attacks 
were  accompanied  by  vomiting  and  rigors,  and  followed  by  jaun- 
dice and  high-coloured  urine  ;  he  had  lost  2  stones  in  weight 
since  the  attacks  first  began  ;  no  tumour  to  be  made  out. 

Operation. — 1 7/5/1898.  Duodeno-choledochotomy  ;  gall-bladder 
atrophied  and  could  not  be  found  ;  large  gall-stone  found  impacted 
in  the  third  part  of  common  duct ;  duodenum  incised ;  stone  size 
of  filbert  extracted  ;  duodenum  sutured  ;  no  drainage. 

After-History. — Good  recovery  ;  letter,  dated  July  24,  1899,  to 
say  that  the  patient  was  well  and  had  returned  to  his  work  as 
goods  guard  on  the  railway. 

Gall-stones,  Gall-bladder -Stomach  Fistula  :  Repair  of  Fistula  ;  Chole- 
cystotomy. 

Case  219. — Mrs.  II.,  aged  sixty,  seen  with  Dr.  Clarke,  Don- 
caster.  Attacks  of  gall-stone  pains  for  fifteen  months,  lately  very 
frequent  and  followed  by  slight  jaundice  ;  loss  of  weight. 


APPENDIX  367 

Operation. — 7/7/1898.  Cholecystotomy  and  detaching  of  adhe- 
sions ;  sinus  between  gall-bladder  and  stomach  excised,  and 
stomach  wall  repaired  ;  gall-stones  removed. 

After -History. — Good  recovery  ;  in  September  attack  of  pain, 
probably  catarrhal,  as  it  soon  passed  off;  regained  weight  formerly 
lost ;  now  well,  1902. 

Gall-stones :  Choledochotomy. 

Case  220. — Mr.  D.,  aged  forty-six,  seen  with  Dr.  Smith,  Don- 
caster.  Attacks  of  epigastric  pain  two  years  with  vomiting,  but 
without  jaundice ;  loss  of  a  stone  in  weight  ;  tumour  present  for 
at  least  six  weeks  ;  slight  jaundice. 

Operation. — 7/7/1898.  Choledochotomy  ;  gall-stones  removed 
from  gall-bladder  by  cholecystotomy  ;  one  impacted  deeply  in 
cystic,  near  the  common,  duct,  removed  by  incising  the  duct, 
which  was  afterwards  sutured. 

After-History. — Good  recovery  ;  now  quite  well. 

Gall-stone  causing  Perceptible  Tumour  :  Cholecystotomy. 

Case  221. — Miss  J.  T.,  aged  thirty,  seen  at  the  infirmary. 
Four  years'  history  of  fairly  constant  pain  in  the  right  hypochon- 
drium  of  a  dull,  aching  character,  considerably  worse  on  exertion, 
and  on  several  occasions  it  radiated  into  the  right  subscapular 
region.  During  the  attacks  she  vomited,  but  never  had  a  rigor  and 
was  never  jaundiced.  On  abdominal  examination,  a  hard,  globular, 
tender  mass  was  felt  below  the  right  costal  margin,  which  was 
freely  movable  from  side  to  side,  and  moved  with  respiration. 

Operation. — 7/7/1898.  Cholecystotomy;  large  oval  stone  weigh- 
ing 1  ounce  30  grains,  and  measuring  i\  by  if  inches,  removed 
from  the  gall-bladder  ;  gall-bladder  drained  for  four  days. 

After -History. — Complete  recovery,  and  well  when  last  seen. 

Gall-stones  in  Common  Duct :  Cholecystotomy. 

Case  222. — Mrs.  P.,  aged  fifty-three,  seen  with  Dr.  Robinson, 
Poole.  No  pain  before  four  months  ago  ;  several  attacks  since ; 
two  months  ago  pain  followed  by  jaundice ;  recurring  pains 
followed  by  deepened  jaundice  and  ague-like  attacks  ;  great  loss 
of  flesh. 

Operation. — 12/7/1898.  Cholecystotomy;  two  large  gall-stones 
the  size  of  walnuts  removed  from  the  common  duct  through  the 
dilated  cystic  duct  and  gall-bladder  ;  twelve  other  smaller  concre- 
tions removed  from  the  gall-bladder  and  cystic  duct ;  pus  in  the. 
gall-bladder. 


368    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Aftev-Histovy. — Good  recovery ;  within  five  weeks  gained  10 
pounds  in  weight  ;  well,  June,  1899 — had  gained  2  stones  in  weight 
and  looked  in  robust  health. 

Gall-stones  in  Common  Duct :  Choledochotomy  ;  Gastrolysis. 

Case  223. — Mrs.  P.  W.,  aged  thirty-four,  seen  with  Dr.  Craik, 
Conisborough.  Four  years'  history  of  attacks  of  pain  commencing 
in  the  epigastrium  and  radiating  to  the  mid-scapular  region  ;  each 
attack  lasted  several  hours,  was  accompanied  by  a  rigor  and 
vomiting,  and  followed  by  jaundice  ;  during  the  last  eight  months 
the  attacks  had  been  more  severe  and  frequent,  the  jaundice  per- 
sisting ;  the  patient  was  deeply  jaundiced  ;  no  distension  of  gall- 
bladder ;  tenderness  on  deep  pressure  below  the  right  costal 
margin. 

Operation. — 21/7/1898.  Choledochotomy;  extensive  adhesions 
between  gall-bladder,  stomach,  duodenum,  and  omentum  separated ; 
gall-bladder  contracted ;  common  duct  blocked  with  stones ; 
stones  extracted  with  scoop  through  incision  in  the  common  duct ; 
duct  closed  with  a  double  row  of  sutures ;  gauze  drainage ; 
recovery  delayed  by  an  attack  of  bronchitis,  to  which  patient  was 
subject ;  jaundice  had  almost  completely  disappeared  when  she 
left  the  hospital. 

Aftcv-History. — Very  well,  September,  1899. 

Gall-stones  :  Clwlecystolomy. 

Case  224. — Mrs.  A.,  aged  thirty-eight,  seen  at  the  infirmary. 
Twenty  years'  history  of  pain  starting  in  the  right  hypochondrium 
and  radiating  to  the  right  scapular  region,  generally  accompanied 
by  vomiting,  but  only  once  by  jaundice  in  one  of  the  first  attacks  ; 
pain  much  more  severe  lately  ;  tenderness  on  pressure  over  the 
gall-bladder  ;  no  tumour  felt. 

Operation. — 5/8/1898.  Cholecystotomy  ;  forty-five  gall-stones 
removed  ;  ducts  clear  ;  gall-bladder  drained  for  six  days. 

After-History, — Patient  did  well  for  three  weeks,  and  then  left 
the  hospital  against  advice. 

Gall-stone  :  Cholecystotomy. 

Case  225. --  Mrs.  S.,  aged  fifty,  seen  at  the  infirmary.  Patient 
suffered  from  spasms  when  a  girl,  but  was  free  from  trouble  up  to 
four  years  ago  ;  since  then  she  had  had  frequent  attacks  of  pain, 
which  had  become  more  severe  during  the  last  six  months.  Pain 
commenced  in  the  right  hypochondrium,  and  radiated  to  the  right 
subscapular  region.  She  had  been  jaundiced  after  two  attacks, 
and  then  gall-stones  had  been  found  in  the  motions. 


APPENDIX  369 

Opevation. — 1 0/8/1 89S.  Cholecystotomy  ;  one  rounded  stone, 
weighing  30  grammes,  removed  from  the  gall-bladder  ;  ducts 
free. 

Aftev-Histovy. — Good  recovery  ;  well  when  last  heard  of. 

Gall-stones  in  Common  Duct  :  Cysto-dochentevostomy ;  Gastvolysis. 

Case  226. — Mrs.  P.,  aged  forty-four,  seen  at  the  infirmary. 
First  attack  of  pain  five  years  ago  ;  another  three  years  ago  ;  free 
from  pain  up  to  eight  months  ago  ;  since  then  attacks  every  few 
weeks  ;  pain  very  severe,  radiating  from  the  right  hypochondrium 
to  the  right  subscapular  region,  accompanied  by  vomiting  and 
always  followed  by  jaundice  ;  no  rigors  ;  tender  swelling  detected 
below  the  right  costal  margin. 

Opevation. — 10/8/1898.  Gall-bladder  found  adherent  to  omentum, 
transverse  colon,  and  pylorus  ;  adhesions  separated  ;  gall-bladder 
very  much  thickened  and  infiltrated  ;  116  stones  removed  from  it 
and  cystic  duct  by  scoop;  common  duct  still  blocked  with  stones; 
condition  of  patient  and  extensive  adhesions  round  the  duct  pre- 
vented free  exposure,  and  rendered  choledochotomy  inadvisable  ; 
dilated  cystic  duct  united  to  duodenum  by  a  Murphy's  button  ; 
incision  in  gall-bladder  closed,  and  stitched  to  aponeurosis  ;  no 
drainage. 

Aftev-Histovy. — Good  recovery  ;  well  when  last  heard  of. 

Gall-stones  :  Cholecystotomy. 

Case  227. — Mr.  S.,  aged  fifty,  seen  with  Dr.  Lambert,  Farsley. 
Four  years  ago  the  patient  had  first  attack  of  pain  over  the  gall- 
bladder, since  which  time  he  had  had  frequent  seizures  ;  occasion- 
ally he  vomited  during  an  attack,  and  on  one  occasion  he  was 
slightly  jaundiced. 

Opevation. — 25/8/1898.  Cholecystotomy ;  gall-bladder  full  of 
thick  ropy  mucus ;  twelve  stones  removed  from  the  cystic  duct ; 
common  duct  clear ;  gall-bladder  drained. 

Aftev-Histovy. — Good  recovery  ;  well  when  last  heard  of. 

Gall-stones  :  Cholecystotomy. 

Case  228. — H.  P.  G.,  female,  aged  twenty-nine,  seen  with  Dr. 
Ross  and  Dr  Denby,  Manningham.  Attacks  of  colic  for  three 
years  ;  at  first  no  jaundice  ;  later  jaundice  followed  attacks,  and 
several  gall-stones  were  found  in  the  motions  ;  absence  of  physical 
signs  except  tenderness  between  the  umbilicus  and  ninth  costal 
cartilage. 

Opevation. — 30/8/1898.     Cholecystotomy  ;    gall-stones    removed 

24 


3?o    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

from   the   gall-bladder    and    cystic    duct ;    drainage   of  the   gall- 
bladder. 

After-History. — Good  recovery. 

Cholecystitis,  Infective  Cholangitis :  Cholecystotomy ;  Subsequent 

Cholecystectomy. 

Case  229. — Mr.  S.,  aged  fifty-six,  seen  with  Dr.  Cattle, 
Nottingham.  Sister  and  brother  suffered  from  gall-stones  ;  four 
years  ago  characteristic  gall-stone  attacks  followed  by  slight 
jaundice ;  occasional  spasms  before  and  since  ;  a  year  ago  began 
with  ague-like  attacks  and  slight  jaundice  lasting  for  six  months  ; 
loss  of  flesh  about  1^  stones ;  tenderness  1  inch  above  and  to  the 
right  of  the  umbilicus ;  no  enlargement  of  the  liver. 

Operation. — 4/9/1898.  Cholecystotomy  ;  very  firm  adhesions  of 
stomach,  omentum,  and  intestine  to  liver  and  gall-bladder  ;  gall- 
bladder shrunken  and  filled  with  muco-pus  ;  no  gall-stones  felt  in 
the  ducts  ;  drainage. 

After-History. — Good  recovery  ;  quite  well  for  some  weeks,  but 
recurrence  of  pain.  Cholecystectomy  performed  with  good  result ; 
in  good  health,  1903. 

Cancer  of  Pancreas  :  Laparotomy. 

Case  230.— Mr.  R.,  aged  sixty,  seen  with  Dr.  Dearden,  Brad- 
ford. Three  years  ago  had  pain  at  the  epigastrium  ;  February, 
1897,  severe  pain  followed,  without  jaundice ;  eleven  months  ago 
another  attack,  followed  by  jaundice,  which  had  persisted ;  great 
loss  of  flesh  ;  had  bled  from  the  bowel. 

Operation. — 6/9/1898.  Exploratory ;  large  mass  infiltrating  liver 
and  involving  the  head  of  the  pancreas  ;  enlarged  gland  in  gastro- 
hepatic  omentum. 

After-History. — Recovered  from  the  operation  and  returned  home 
apparently  relieved. 

Chronic  Catarrhal  Cholecystitis  :  Cholecystotomy. 

Case  231. — Mrs.  H.,  aged  thirty-five,  seen  with  Dr.  Rowe, 
Cowling.  Ten  years  ago  the  patient  was  treated  for  gastric 
ulcer ;  recovered  and  enjoyed  good  health  up  to  two  years  ago  ; 
she  then  had  several  attacks  within'  a  few  weeks,  of  pain  in  the 
epigastrium,  radiating  to  the  back  ;  pain  severe,  and  accompanied 
by  vomiting  and  rigors;  no  jaundice;  under  treatment  she 
recovered  and  remained  free  from  pain  till  November,  1897, 
when  she  had  attacks  of  pain  accompanied  by  rigors  and 
followed  by  jaundice ;  right  lobe  of  liver  enlarged ;  gall-bladder 
could  not  be  felt. 


APPENDIX  371 

Operation.  — 15/9/1898.  Gall-bladder  exposed,  adherent  to 
omentum  and  colon  ;  distended  with  mucus  ;  no  gall-stones  found  ; 
gall-bladder  drained  for  a  fortnight.  Diagnosis  :  Chronic  catarrhal 
cholecystitis,  a  sequence  of  gall-stones. 

A ftev- History. — Good  recovery  ;  no  recurrence  of  attacks. 

Gall-stones,  Cancer  of  Bile-ducts  :  Cholecysiotomy. 

Case  232.  Miss  B.,  aged  forty-eight,  seen  with  Dr.  Goldsmith, 
Bedford.  Spasms  twenty  years  ago  without  jaundice  ;  no  recur- 
rence till  six  weeks  ago,  when  jaundice  supervened  and  continued 
with  rapid  loss  of  flesh  and  strength,  and  with  nausea  and  vomit- 
ing ;  tenderness  over  gall-bladder,  but  no  tumour  to  be  felt ;  patient 
very  stout. 

Operation. — 21/9/1898.  Cholecystotomy ;  four  gall-stones  re- 
moved from  the  gall-bladder  and  cystic  duct  ;  tumour  felt  at  the 
junction  of  cystic  and  common  duct,  hard  and  nodular  ;  no  other 
gall-stones  felt  ;  drainage  of  the  gall-bladder  by  a  tube  which  was 
shut  off  from  the  peritoneal  cavity  by  suturing  the  omentum 
around  the  opening  in  the  gall-bladder. 

After-History. — Recovered  from  the  operation  and  was  relieved; 
wound  healed  entirely  by  first  intention  except  at  the  site  of  the 
tube;  no  bile  appeared  till  the  ninth  day ;  it  then  flowed  freely 
till  the  fourteenth  day,  when  it  ceased,  probably  owing  to  the 
growth  advancing  to  the  hepatic  duct.  After  the  obstruction 
became  complete  the  jaundice  returned.  Life  was  prolonged  for 
several  months,  and  the  patient  was  freed  from  serious  pain. 

Gall-stones,  Apparent  Cancer  of  Liver  :  Remarkable  Relief  by 

Exploration. 

Case  233. — Mr.  F.,  aged  thirty-nine,  seen  with  Dr.  McCallum, 
Kendal.  Five  well-marked  attacks  of  gall-stones  and  numerous 
slighter  ones  in  five  years  ;  gall-stones  found  in  the  motions ; 
absence  of  enlargement  of  the  gall-bladder  and  liver. 

Operation. — 22/9/1898.  Exploratory;  gall-stones  found  in  the 
gall-bladder,  but  gall-bladder  and  liver  infiltrated  with  what 
appeared  to  be  cancer,  which  had,  however,  not  formed  sufficiently 
large  nodules  to  be  felt  through  the  abdominal  wall. 

After-History. — Great  relief  from  the  operation  ;  jaundice  had 
almost  disappeared  when  he  left  Leeds  at  the  month  end  ;  May 
24,  1899,  patient  very  well ;  has  had  no  pain  since  the  operation, 
and  has  gained  weight.  The  good  result  of  exploration  in  this  case 
is  to  me  quite  inexplicable,  as  the  case  had  every  appearance  of 
cancer. 

24 — 2 


372    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCT  $ 

Gall-stones,  Tumour  of  Cystic  Duct :  Cholecystectomy  and 
Hepatectomy. 

Case  234.— Miss  \\\,  aged  forty,  seen  with  Dr.  Nicholson 
Dobie,  Keighley.  Strong  family  history  of  phthisis  ;  in  twelve 
months  several  attacks  of  severe  pain  in  the  right  iliac  region, 
accompanied  by  swelling  in  normal  situation  of  the  caecum,  and 
marked  tenderness  between  the  anterior  superior  spine  of  ilium  and 
umbilicus ;  each  attack  was  associated  with  fever,  constipation, 
vomiting,  and  abdominal  swelling,  and  all  signs  of  local  peritonitis 
over  inflamed  appendix. 

Operation.  —  29/9/1898.  Cholecystectomy  and  hepatectomy; 
incision  over  caecum ;  viscera  matted  together  by  old  and  recent 
lymph  ;  after  separating  adhesions,  the  gall-bladder  was  reached 
at  the  end  of  a  projecting  Riedel's  lobe ;  muco-pus  and  several 
gall-stones  were  removed  ;  tumour  of  cystic  duct  felt,  and  as  on 
incision  it  gave  the  appearance  of  growth,  it,  with  the  gall-bladder, 
was  removed  by  means  of  an  elastic  ligature.  Mr.  Targett 
reported  the  tumour  to  be  inflammatory,  and  not  due  to  tubercle 
or  cancer. 

After-History. — Satisfactory  recovery ;  quite  well  four  years 
later. 

Obstructed  Bile-duct,  Recurring  Pain,  Jaundice  :  Cholecystotomy. 

Case  235. — Mrs.  S.,  aged  fifty,  seen  at  the  infirmary.  Two 
years'  history  of  attacks  of  abdominal  pain,  commencing  about  the 
umbilicus,  radiating  to  the  back ;  attacks  were  of  moderate 
severity,  and  occurred  at  frequent  intervals  ;  no  vomiting  or  rigors. 
Three  weeks  ago,  after  a  severe  attack  of  pain,  the  patient  became 
jaundiced,  with  clay-coloured  motions  and  high-coloured  urine. 
Jaundice  had  persisted,  and  she  had  had  several  attacks  of  pain ; 
one  in  the  infirmary  was  very  severe.  Tender  spot  above  and  to 
the  right  of  the  umbilicus  ;  no  distended  gall-bladder  could  be 
felt. 

Operation. — 3/1 0/1898.  Cholecystotomy;  no  gall-stones  felt  in 
the  gall-bladder  or  bile-ducts,  but,  as  jaundice  was  thought  to  be 
obstructive,  cholecystotomy  was  performed.  Beyond  severe 
vomiting  for  the  first  day  or  two,  there  appeared  to  be  no  cause 
for  anxiety,  but  on  October  10  the  patient  died  suddenly, apparently 
from  syncope. 

Post-mortem  Examination.  —  The  kidneys  were  found  to  be 
granular,  and  the  capsules  very  adherent,  but  beyond  this 
nothing  was  found  to  account  for  death.  So  far  as  the  operation 
was  concerned,  everything  was  satisfactory.  The  wound  was 
healed,  and  there  were  no  signs  of  peritonitis. 


APPENDIX  373 

Gall-stones  in  Common  Duct,  Jaundice,  Suppurative  Cholangitis,  Heart 

Disease  :  Choledochotomy. 

Case  236. — Mrs.  M.,  aged  fifty-five,  seen  with  Dr.  Gordon 
Black,  Harrogate.  Six  years  ago  influenza ;  four  months  after 
severe  pain  over  the  liver  and  on  the  left  side  of  the  abdomen  ; 
pain  off  and  on  for  six  weeks,  when  jaundice  appeared  ;  since  then 
frequent  ague-like  attacks  with  jaundice  and  fever ;  great  loss  of 
flesh  ;  oedema  of  the  legs  ;  pulse  108,  feeble  ;  severe  mitral  disease 
and  dilated  heart,  with  albuminuria  ;  liver  large  ;  swelling  at  site 
of  gall-bladder  hard  ;  no  nodules  felt  in  the  liver.  Patient  seen  a 
month  before  but  thought  too  ill  for  operation,  and  general  treatment 
advised,  but  when  seen  a  month  later,  as  she  was  manifestly  going 
to  die  if  not  relieved,  operation  was  reluctantly  decided  on  to  give 
her  a  last  chance,  especially  as,  under  digitalis,  the  heart  seemed 
to  have  improved  sufficiently  to  warrant  it. 

Operation. — 19/10/1898.  Choledochotomy;  many  adhesions; 
common  bile-duct  incised  and  several  gall-stones  removed  ;  finger 
passed  up  into  the  cystic  and  hepatic  ducts,  which  were  occupied 
by  gall-stones  that  were  then  removed  by  the  scoop;  duct  sutured; 
drainage  of  abdomen. 

After-History. — Death  from  exhaustion  and  heart  failure  sixth 
day. 

Gall-stones :  Cholecystotomy. 

Case  237. — Mrs.  R.,  aged  forty-seven,  seen  at  the  infirmary. 
Six  years'  history  of  attacks  of  biliary  colic  accompanied  by  rigors 
and  vomiting  ;  attacks  more  frequent  and  severe  during  the  last 
six  months,  usually  followed  by  jaundice,  which  cleared  up  between 
the  attacks ;  tenderness  on  palpation  above  and  to  the  right  of  the 
umbilicus ;  no  swelling  to  be  felt. 

Operation. — 20/10/1898.  Cholecystotomy  ;  thirteen  stones  re- 
moved from  the  gall-bladder  and  cystic  duct  ;  drainage. 

After-History. — Good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  238. — Mrs.  B.,  aged  sixty-two,  seen  with  Dr.  Irving, 
Huddersfield.  Attacks  of  so-called  '  visceral  neuroses  '  ten  years  ; 
no  jaundice  except  once,  a  year  ago,  which  lasted  four  days  ;  single 
faceted  gall-stone  found  in  the  motions  after  the  attack  :  urine 
normal ;  no  heart  disease  ;  slight  oedema  of  the  ankles  ;  gall-bladder 
distended  and  tender. 

Operation. — 22/10/1898.  Cholecystotomy;  fifty-nine  gall-stones 
removed,  varying  from  the  size  of  a  small  pea  to  that  of  a  cherry  ; 
drainage  of  the  gall-bladder. 

After-History. — Good  recovery  ;  well,  July,  1S99. 


374    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Chronic  Pancreatitis,  Jaundice,  and  Infective  Cholangitis  :  Exploratory 

Operation. 

Case  239. — Mr.  D.,  aged  forty-two,  seen  with  Dr.  Chaffers, 
Keighley.  Ten  years  ago  an  attack  of  pain  in  the  right  hypo- 
chondrium  ;  no  jaundice  ;  free  from  attacks  up  to  six  weeks  ago  ; 
he  had  then  had  a  severe  attack  of  pain  in  the  right  hypochondrium 
radiating  to  the  back  and  shoulders,  accompanied  by  rigors  and 
vomiting,  and  followed  by  jaundice ;  jaundice  had  persisted  up  to 
the  present ;  no  swelling  to  be  felt. 

Operation. — 27/10/1898.  Exploratory  laparotomy;  mass  of 
growth  in  the  head  of  the  pancreas ;  wound  closed. 

After-History. — Recovery,  with  great  relief  to  jaundice.  I  sus- 
pect the  enlargement  of  the  head  of  the  pancreas  was  chronic 
pancreatitis,  as  it  was  too  soft  for  scirrhus.  I  very  freely  manipu- 
lated it  to  feel  if  there  was  a  gall-stone  in  the  termination  of  the 
common  bile-duct,  and  this  may  have  dislodged  something  from 
the  pancreatic  duct.     Ultimately  complete  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  240. — Mr.  W.,  aged  sixty-two,  seen  with  Dr.  Brown, 
Denby  Dale.  Attacks  of  abdominal  pain,  more  in  lower  abdomen, 
for  twenty  years,  sometimes  followed  by  jaundice,  occasionally 
followed  by  vomiting,  which  relieved  the  pain ;  loss  of  flesh, 
general  feebleness,  and  low  specific  gravity  of  urine  ;  tenderness 
below  and  to  the  right  of  the  umbilicus  ;  markedly  pulsating  aorta 
with  questionable  tumour  above  the  umbilicus  ;  fulness  in  the 
gall-bladder  region.  At  first  thought  to  be  too  ill  for  operation, 
but,  after  watching  him  for  a  fortnight,  with  some  improvement, 
operation  thought  feasible. 

Operation. — 16/11/1898.  Cholecystotomy;  285  stones  removed 
from  the  gall-bladder  and  cystic  duct.  Smooth  recovery  from 
operation,  and  wound  healed.  Cerebral  symptoms  and  partial 
paralysis  developed  on  the  thirtieth  day,  and  ended  in  coma  on 
the  thirty-fourth  day  from  operation. 

After -History. — Recovery  from  the  operation,  but  death  thirty- 
fourth  day.  Autopsy :  Cerebral  thrombosis ;  no  peritonitis ;  a 
small  gall-stone  found  in  the  common  duct ;  kidneys  diseased. 

Gall-stones,  Ulceration  and  Perforation  of  Gall-bladder  :  Cholecystotomy. 

Case  241. — Mrs.  I.,  aged  forty-eight,  seen  with  Dr.  Irving, 
Huddersfield.  Spasms  for  fifteen  years,  lately  more  frequent ; 
loss  of  4  stones  5  pounds  in  thirteen  years  ;  loss  of  1  stone  in  weight 
lately  ;  attacks  of  pain  began  at  the  epigastrium  and  passed  to  the 
shoulder  ;  jaundice  once  after  an  attack  ;  albuminuria,  but  no  tube- 
casts  ;  tenderness  over  the  gall-bladder  ;  no  tumour. 


APPENDIX  37 5 

Operation. — 21/11/1898.  Cholecystotomy  ;  stone  ulcerating  its 
way  out  at  the  fundus,  and  half  extruded  into  peritoneal  cavity  ; 
no  adhesion  at  that  part,  but  adhesions  lower  down. 

A ftev- History. — Good  recovery. 

Cancer  of  Head  of  Pancreas,  Jaundice  :  Cholecy  stenter ostomy . 

Case  242. — Mr.  J.,  aged  sixty-one,  seen  at  the  infirmary. 
Jaundice  for  eight  weeks,  with  little  pain  ;  no  history  of  gall-stones  ; 
feeling  of  discomfort  over  the  gall-bladder,  which  was  distended ; 
loss  of  weight  very  considerable. 

Operation. — 1/12/1898.  Cholecystenterostomy  ;  cancer  of  the 
head  of  the  pancreas;  Murphy's  button  used. 

After-History. — Recovery  ;  button  passed  sixteenth  day. 

Gall-stone  in  Ampulla  of  Vater,  Sub-Diaphragmatic  Abscess  :  Duodeno- 

Choledochotomy . 

Case  243. — Mrs.  L.,  aged  forty-nine,  seen  with  Dr.  Lee,  Dews- 
bury.  Spasms  for  five  years  ;  jaundice  first  three  and  a  half  years 
ago  ;  sickness  and  jaundice  without  pain  off  and  on  since  ;  jaundice 
continuous  for  five  weeks ;  ague-like  attacks  two  months  ago,  and 
five  or  six  weeks  since  ;  examination  negative  ;  no  tenderness  ;  no 
tumour  ;  great  loss  of  flesh  ;  some  continuous  fever,  and  great 
feebleness. 

Operation. — 1/12/1898.  Duodeno-choledochotomy  ;  gall-stone 
in  the  ampulla  of  Vater  removed  through  the  duodenum  ;  no  drain- 
age ;  wound  reopened  the  seventh  day  on  account  of  fever  and 
pain  in  the  abdomen,  but  nothing  abnormal  found. 

After-History. — Death  sixteenth  day.  Autopsy :  duodenal  wound 
healed ;  collection  of  pus  between  the  liver  and  diaphragm  evidently 
of  some  duration,  but  not  discovered  at  the  time  of  operation,  or 
on  reopening  the  wound. 

Catarrhal  Cholecystitis  :  Cholecystotomy  ;  Gastrolysis. 

Case  244. — Mr.  D.,  aged  fifty-two,  seen  with  Dr.  Holdsworth, 
Birmingham,  and  Mr.  R.  N.  Hartley,  Leeds.  First  attack  fifteen 
years  ago,  numerous  seizures  since,  and  recurring  more  frequently 
recently  ;  latterly  stomach  troubles  ;  no  tumour  ;  tenderness  over 
the  gall-bladder  ;  dilatation  of  stomach. 

Operation. — 14/ 12/ 1898.  Cholecystotomy  ;  contracted  gall- 
bladder ;  adhesion  of  pylorus  and  intestine  to  it  and  to  liver  ; 
gall-bladder  much  thickened ;  cystic  duct  strictured  ;  drainage ; 
funnel  of  omentum  used  to  shut  off  the  peritoneal  cavity  ;  visceral 
adhesions  separated. 

After-History. — Good  recovery  ;  quite  well,  1902. 


376    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Catarrhal  Cholecystitis,  Dilated  Stomach  :  Cholecystotomy  ; 

Gastrolysis. 

Case  245. — Mrs.  N.,  aged  fifty-seven,  seen  with  Dr.  Halliday, 
Armley.  Well  till  eight  months  ago;  never  had  spasms  or  jaun- 
dice ;  six  attacks  in  eight  months ;  pain  severe,  beginning  at  the 
epigastrium,  and  passing  to  the  right  infrascapular  region ;  examina- 
tion negative  but  for  tenderness  over  the  gall-bladder. 

Operation. — 1 5/1 2/1 898.  Cholecystotomy;  much  adherent  and 
dilated  stomach  ;  contracted  gall-bladder,  containing  thick  mucus  ; 
separation  of  adhesions  ;  tube  fixed  into  the  gall-bladder  and 
isolated  by  iodoform  gauze. 

After-History. — Good  recovery. 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Case  246. — Mrs.  P.,  aged  fifty-nine,  seen  with  Dr.  I'Anson, 
Whitehaven.  Stomach  troubles  for  years,  but  no  definite  biliary 
colic  till  two  years  ago,  since  which  many.  With  last  attack- 
rigor  and  elevated  temperature,  but  no  jaundice ;  distended  gall- 
bladder. 

Operation. — 17/12/1898.  Inflamed  gall-bladder,  containing  about 
4  ounces  of  pus ;  single  stone  the  size  of  a  starling's  egg  in  cystic 
duct  worked  back  to  the  gall-bladder  and  extracted ;  common  duct 
clear. 

After-History. — Good  recovery;  well,  December,  1899. 

Gall-stones,  Jaundice,  and  Distended  Gall-bladder  :  Cholecystotomy. 

Case  247. — Mr.  R.,  aged  forty-seven,  seen  with  Dr.  Moore, 
Holbeck.  Gall-stone  colic  at  intervals  for  four  and  a  half  years, 
with  intermittent  jaundice ;  no  rigors ;  jaundice  present ;  gall- 
bladder distended  and  tender. 

Operation. — 23/12/1898.  Cholecystotomy;  180  stones  removed 
from  gall-bladder  and  ducts  varying  from  size  of  a  pea  to  that  of 
a  marble. 

After-History. — Good  recovery. 

Gall-stones,  Heart  Disease  :  Cholecystotomy. 
Case  248. — Mr.  D.  S.  B.,  aged  sixty-six,  seen  with  Dr.  Barrs, 
Leeds.  First  attack  eleven  years  ago;  intermission  for  two  years; 
since  more  frequent ;  three  attacks  last  month.  Distension  of 
gall-bladder  for  eight  years  ;  slight  jaundice  almost  continuous  for 
years,  but  worse  after  each  seizure ;  never  extreme ;  had  had 
mitral  disease  for  years  ;  recently  slight  oedema  of  the  feet  at 
nights;  tenderness  over  gall-bladder;  no  tumour;  no  dilatation 
of  stomach;  urine  normal;  loud  mitral  regurgitant  murmur; 
slight  jaundice. 


APPENDIX  377 

Operation. — 6/1/1899.  Cholecystotomy  ;  single  stone  in  shrunken 
gall-bladder,  which  was  very  friable  ;  tube  stitched  into  the  gall- 
bladder, which  could  not  be  brought  up  to  surface ;  drainage  of 
the  right  kidney  pouch. 

A fley- History. — Little  immediate  shock,  but  failure  of  the  heart 
on  the  second  day.  Death  the  fourth  day,  with  symptoms  of 
pneumonia  ;  no  peritonitis. 

Gall-stones,  Dilated  Stomach  :  Cholecystotomy ;  Gastrolysis. 

Case  249.— M.  H.,  female,  aged  thirty-one,  seen  with  Dr.  Bruce, 
Grimsby.  Indefinitely  ailing  three  and  a  half  years  ;  five  attacks 
of  acute  gall-stone  colic  during  the  last  year ;  never  jaundiced  ;  no 
rigors  ;  pain  usually  began  at  the  left  side,  but  always  passed  to 
the  right  shoulder ;  no  tumour ;  tenderness  over  the  gall-bladder  ; 
dilated  stomach. 

Operation. — 13/1/1899.  Cholecystotomy;  four  stones  removed 
from  the  cystic  duct  and  gall-bladder ;  gall-bladder  slightly  dis- 
tended ;  pylorus  adherent  ;  adhesions  broken  down. 

After-History. — Persistent  vomiting  for  four  days,  followed  by  a 
good  recovery.  At  no  time  was  there  distension,  nor  did  the 
pulse-rate  rise. 

Biliary  Fistula  :  Cholecystectomy  ;  Cystodochcnterostomy. 

Case  250. — Mrs.  S.,  aged  forty-eight,  seen  with  Dr.  Saunders, 
Wales.  Cholecystotomy,  April,  1S98;  wound  healed  and  patient 
made  a  good"  recovery,  but  some  time  after,  a  fistula  developed 
and  continued  to  discharge  muco-pus  and  bile,  closing  from  time 
to  time,  only,  however,  to  require  opening  up.  As  each  attack 
was  accompanied  by  fever  and  considerable  distress,  and  as 
swelling  could  be  felt  beneath  the  right  costal  margin,  operation 
was  advised. 

Operation. — 19/1/1899.  Cholecystectomy  and  cystodochenter- 
ostomy  ;  peritoneal  cavity  opened  ;  numerous  adhesions  found  ; 
all  landmarks  obliterated  ;  gall-bladder  and  ducts  examined,  but 
no  evidence  of  blockage  ;  chain  of  hardened  glands  felt  along  the 
course  of  the  common  duct  ;  gall-bladder  contracted,  and  as  it 
was  lacerated  in  detaching  adhesions,  it  was  removed  and  the 
cystic  duct  connected  by  means  of  a  Murphy's  button  with  the 
duodenum ;  the  liver  was  slightly  lacerated  in  separating  adhesions. 

After-History. — Imperfect  drainage  and  extravasation  of  infected 
bile  from  the  torn  surface  of  the  liver  was  responsible  for  the 
fatality,  which  occurred  on  the  fifth  day.  The  artificial  union 
between  the  bile-duct  and  gut  was  perfect. 


378    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

Cancer  of  Pancreas,  Jaundice,  Ascites  :  Cholecystotomy. 

Case  251. — Mrs.  M.  K.,  aged  thirty-four,  seen  with  Dr.  Coombs, 
Bedford.  No  history  of  spasms;  influenza,  December  3,  1898; 
patient  became  jaundiced  on  December  20,  1898  ;  without  pain  ; 
the  jaundice  continued.  On  January  16,  1899,  she  became 
feverish;  temperature  1040  ;  fever  continued,  hectic  type;  at  first 
liver  enlarged  and  very  tender  ;  cough  throughout  always  pro- 
voked by  pressure  on  the  gall-bladder  ;  no  physical  signs  in  the 
chest ;  never  had  pain  ;  the  pulse  was  slow  throughout  ;  ascites 
present,  with  deep  jaundice  and  fever. 

Operation.  —  24/1/1899.  Exploratory;  blood  effusion  in  the 
sheath  of  rectus,  and  a  large  amount  of  ascitic  fluid  let  out ;  no 
gall-stones  or  tumour  felt,  but  doubtful  swelling  at  the  head  of 
the  pancreas,  and  cirrhosis  of  the  liver  ;  disease  probably  cancer 
of  the  papilla,  with  extension  to  pancreas  and  with  subsequent 
infective  cholangitis  ;  gall-bladder  drained. 

After-History. — Shock  and  exhaustion  led  to  death  on  the  third 
day.    No  autopsy. 

Cancer  of  Liver,  Gall-bladder,  and  Cystic  Duct,  with  Gall-stones : 

Laparotomy. 

Case  252. — Mr.  B.,  aged  fifty-five,  seen  with  Dr.  Batchelor, 
Dunedin,  New  Zealand.  Attacks  of  biliary  colic  for  twenty-five 
years  till  January,  1893,  then  an  interval  till  July,  1898,  when  he 
had  dyspeptic  troubles.  Jaundice  in  August  without  any  colic, 
and  persisting  since  ;  no  pain  or  rigor  since ;  great  loss  of  flesh  ; 
liver  enlarged ;  lower  border  felt  3  inches  below  the  ribs  ;  nodule 
felt  in  the  epigastrium  ;  deep  jaundice  present. 

Operation. — 25/2/1899.  Exploratory  ;  cancer  of  the  gall-bladder 
and  cystic  duct,  with  secondary  deposit  in  the  liver ;  many  gall- 
stones in  the  gall-bladder.     Wound  healed  by  first  intention. 

After -History. — Patient  seemed  to  pick  up  strength  after  the 
operation,  and  returned  to  London,  where  he  died,  apparently 
from  syncope,  seven  weeks  after  the  operation. 

Fistula  discharging  Muco-pus,  Epithelioma  of  Gall-bladder  :  Chole- 
cystotomy. 

Case  253. — Mrs.  D.,  aged  fifty-two,  seen  with  Dr.  Ferguson, 
Thirsk.  Cholecystotomy,  January,  1898  ;  well  till  September, 
1898,  when  she  had  had  pain  and  tenderness  in  the  gall-bladder 
region.  In  October  an  abscess  formed  and  burst  externally, 
since  which  time  there  had  been  a  muco-purulent  discharge  from 
the  sinus. 

Operation. — 22/1/1899.  Cholecystotomy;  large  mass,  hard  and 
irregular,    found    where    the    gall-bladder    was    attached    to    the 


APPENDIX  379 

parietes  ;  part  removed  for  examination  ;   tube  inserted  into  the 
gall-bladder. 

After  -  History.  —  Recovery;  tumour  found  to  be  cylindrical 
epithelioma.  The  wound  healed,  and  the  patient  returned  home 
within  a  month. 

Gall-stones  :  Cholecystotomy. 

Case  254. — Mrs.  D.,  aged  fifty-six,  seen  with  Dr.  Mann  and 
Dr.  Woodcock,  Leeds.  Spasms  three  years,  with  intermittent 
jaundice;  loss  of  flesh;  distended  gall-bladder,  tender;  slight 
jaundice  present. 

Operation. — 2/3/1899.  Cholecystotomy;  dumb-bell-shaped  stone 
j  \  inches  long  in  gall-bladder ;  another  smaller  stone  blocking  the 
cystic  duct  pressed  back  into  the  gall-bladder  and  extracted. 

After-History. — Good  recovery. 

Gall-stones  in  Ampulla,  Adhesions  :  Duodeno-Choledochotomy. — Acute 

Dilatation  of  Stomach. 

Case  255. — Miss  A.  G.,  aged  twenty-seven,  seen  with  Dr. 
Thompson,  Mytholmroyd  First  attack  fifteen  months  ago,  with 
jaundice ;  never  free  from  jaundice  since,  but  increasing  with  each 
seizure;  latterly  very  marked;  recently,  slight  epistaxis  ;  no  rigors; 
deep  jaundice;  tumour  in  the  right  hypochondrium  like  a  distended 
gall-bladder  ;  liver  dulness  increased. 

Operation. — 9/3/1899. — Duodeno-choledochotomy  ;  Riedel's  lobe 
and  distended  gall-bladder;  stone  impacted  at  the  ampulla  of 
Vater  removed  through  duodenum ;  another  stone  higher  up 
removed  by  the  scoop;  duodenal  wound  closed;  gauze-drain  down 
to  incision. 

After-History. — Well  until  the  evening  of  the  15th,  with  a 
normal  pulse  and  temperature ;  sudden  rise  of  pulse  and  vomiting, 
which  continued  till  the  17th,  when  the  patient  died.  Post- 
mortem :  No  peritonitis;  superficial  wound  and  the  wound  in  the 
duodenum  healed  ;  stomach  much  dilated ;  omental  adhesion 
binding  the  first  part  of  the  duodenum  to  the  pyloric  end  of  the 
stomach.  Death  apparently  due  to  heart  failure  from  pressure  of 
acutely  dilated  stomach  ;  nothing  else  found  to  account  for  the 
fatal  result. 

Gall-stones    in    Common    Duct,  Jaundice   and   Infective   Cholangitis  : 

Cholecyst  enterostomy. 

Case  256. — Mr.  W.,  aged  sixty-five,  seen  with  Dr.  Paton, 
Sowerby  Bridge.  For  a  year  repeated  attacks  of  gall-stone  colic, 
now  recurring  every  eight  days  ;  lately  followed  by  jaundice, 
varying  in  severity,  but  never  absent  ; ^attacks  latterly  associated 


380    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

with  rigors ;  no  gastric  disturbance  ;  no  tenderness ;  liver  some- 
what depressed  ;  no  tumour  ;  heart-sounds  weak  ;  arteries  athero- 
matous ;  albuminuria  ;  patient  emaciated. 

Operation. — 10/3/1899.  Cholecystenterostomy  ;  large  stone  in 
the  common  duct,  but  the  patient  was  too  weak  to  bear  a  pro- 
longed operation  ;  Murphy's  button  passed  on  the  tenth  day. 

Aftcv-Histovy. — Recovery ;  patient  very  weak  from  the  third  to 
the  seventh  day,  with  some  delirium,  after  which  a  good  re- 
covery ;  relieved  for  some  months,  but  then  some  recurrence  of 
symptoms. 

Cholecystitis :  Cholecystectomy. 

Case  257. — Mr.  S.,  aged  fifty-six,  seen  with  Dr.  Anderson, 
Nottingham.  Cholecystotomy  for  contracted  gall-bladder  and 
adhesions,  September  4,  1898,  followed  by  relief  for  some  time, 
but  rigors  recurred. 

Operation. — 9/3/1899.  Cholecystectomy  ;  removal  of  gall-bladder 
containing  muco-pus  ;  cystic  duct  apparently  strictured ;  no  bile 
flowed  at  the  time  of  operation,  but  drainage-tube  inserted  down 
to  the  cystic  duct ;  free  flow  of  bile  following  day. 

After-History. — Good  recovery  ;  in  good  health,  1903. 

Gall-stones  in   Common  Duct,  Jaundice   and   Infective    Cholangitis : 
Choledochotomy  and  Cholecystotomy. 

Case  258. — Mrs.  B.,  aged  fifty-six,  seen  with  Sir  Henry  Blanc  and 
Dr.  McDougall,  Cannes.  Gall-stone  colic  twenty  years  ago  ;  no 
recurrence  till  January,  1898,  since  which  time  frequent  attacks; 
jaundice  persisted  for  six  months,  but  varying  in  intensity  with 
the  seizures  ;  for  some  weeks  elevation  of  temperature  (1010,  1020, 
and  1030)  ;  in  the  evening  chilly  feeling,  but  no  rigors  ;  great  loss 
of  flesh. 

Operation. — 16/3/1899.  Choledochotomy;  gall-bladder  con- 
tracted on  a  faceted  gall-stone  size  of  a  bean  ;  floating  gall-stone 
in  a  much  dilated  common  duct  removed  by  an  incision  in  the 
duct ;  gall-bladder  drained  ;  gauze-drain  into  the  right  kidney- 
pouch  removed  at  the  end  of  thirty-six  hours. 

After-History. — Good  recovery  ;  well,  1903. 

Gall-stones,  Empyema  of  Gall-bladder  :  Choledochotomy,  Cholecystotomy. 

Case  259. — Mrs.  G.,  aged  forty-seven,  seen  with  Dr.  Lambert, 
Farsley.  Repeated  gall-stone  seizures  for  two  years  ;  no  jaun- 
dice ;  no  shivers;  distended  gall-bladder,  which  was  tender  ;  no 
fever. 

Operation. — 23/ '3/1899.  Choledochotomy;  empyema  of  gall- 
bladder;  many  small  stones  in  the  gall-bladder  ;_one  large  stone 


APPENDIX  381 

removed  from  the  cystic  duct  by  choledochotomy  ;  drainage  of 
the  gall-bladder,  and  a  gauze-drain  down  to  the  incision  in  the 
duct. 

Aftev-Histovy. — Cured. 

Typhoidal  Cholecystitis,  Gall-stones,  Adhesions  :  Gaslvolysis,  etc. 

Case  260. — Mr.  T.,  aged  thirty,  seen  with  Dr.  Harvey,  London, 
and  Dr.  Turner,  York.  Attacks  of  gall  stone  colic  for  twelve 
years;  typhoid  fever  in  September,  1898;  very  severe  attack  of 
infective  cholangitis  in  January,  1899.  This  cleared  off,  and  the 
patient  was  in  fair  condition  in  April.  Tenderness  over  the  gall- 
bladder region  ;  no  tumour ;  no  dilatation  of  the  stomach  ;  pulse 
soft  but  slow. 

Operation. — 4/5/1899.  Separation  of  visceral  adhesions  to  gall- 
bladder and  bile-ducts.  At  operation  many  adhesions  of  stomach 
to  the  gall-bladder  and  liver  ;  small  gall-bladder  very  high  up 
under  the  ribs ;  several  stones  impacted  deeply  in  the  cystic 
duct.  Under  anaesthetic  the  patient's  pulse  ran  up  to  150,  and 
only  separation  of  adhesions  was  done,  as  the  gall-stones  seemed 
fixed,  and  it  was  thought  they  might  not  give  further  trouble,  the 
later  attacks  being  probably  due  to  visceral  adhesions. 

Aftev-Histovy.  —  Good  recovery;  well,  December,  1899;  re_ 
gained  his  lost  weight ;  did  good  service  throughout  the  Boer 
War. 


Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 
Choledochotomy  and  Cholecystotomy. 

Case  261. — Mrs.  A.,  aged  forty-eight,  seen  writh  Dr.  Bramwell, 
Cheltenham.  Innumerable  attacks  of  gall-stone  colic,  usually 
followed  by  jaundice,  sometimes  lasting  a  month,  but  lately  more 
transient;  attacks  recently  milder,  but  more  frequent,  and  latterly 
there  had  been  rigors  with  the  seizures ;  attacks  of  localized  peri- 
tonitis twelve  months  ago ;  slight  tinge  of  jaundice  ;  physical 
examination  negative. 

Opevation. — 6/5/1899.  Choledochotomy  ;  numerous  adhesions 
broken  down  ;  numerous  stones  removed  from  the  gall-bladder 
and  the  cystic  duct;  three  removed  from  the  common  duct 
through  twro  incisions,  as  one  of  the  stones  was  encysted  and 
required  separate  incision  ;  drainage  of  the  gall-bladder  and  right 
kidney-pouch  ;  both  wounds  in  the  common  duct  stitched  up. 

Aftev-Histovy. — Very  considerable  discharge  from  the  kidney- 
pouch  for  a  week,  otherwise  a  good  recovery ;  no  peritonitis  ; 
well,  1903. 


382    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones,  Pain  always  Left  Side  :  Cholecystotomy ;  Gastvolysis. 

Case  262. — Mrs.  H.,  seen  with  Dr.  Brown,  Roundhay.  Typhoid 
fever  twenty  years  ago,  with  cholecystitis ;  attacks  of  spasms  on 
left  side  of  abdomen  for  years;  no  jaundice  till  November,  1898, 
since  which  time  jaundice  after  each  attack ;  no  rigors ;  lost 
ih  stones  in  weight  in  twelve  months.  Pain  began  at  the  left 
of  the  epigastrium,  and  radiated  to  the  back  and  to  both  shoulders  ; 
vomiting  a  marked  feature  of  the  case  ;  never  vomited  blood  ; 
latterly  pain  rather  more  on  the  right  side,  but  still  most  marked 
on  the  left ;  tenderness  under  the  left  costal  margin  and  over  the 
gall-bladder,  but  no  tumour  felt. 

Operation. — 8/5/1899.  Cholecystotomy ;  five  stones  removed 
from  the  gall-bladder,  one  manipulated  back  from  the  cystic  duct; 
pylorus  adherent  to  the  cystic  duct  just  over  the  stone  ;  adhesions 
of  stomach  to  the  liver  and  to  ducts  broken  down. 

A ftev '-History. — Good  recovery  ;  well,  December,  1899. 

Jaundice,  Infective  Cholangitis  :  Adhesions  strict uring  Common  Duct 
Separated ;    Gastrolysis. 

Case  263. — Mrs.  F.,  aged  forty-two,  seen  with  Dr.  Woodyatt, 
Halifax.  Gall-stone  colic  every  three  weeks  for  two  years;  jaun- 
diced for  three  months ;  ague-like  attacks  recently  ;  no  tumour  ; 
tenderness  over  the  gall-bladder  ;  well-marked  jaundice. 

Operation. — 8/5/1899.  Separation  of  adhesions  around  common 
duct  ;  very  dense  adhesions  of  stomach  and  pylorus  to  the  gall- 
bladder and  liver  ;  gall-bladder  shrunken  ;  common  duct  strictured 
by  adhesions  ;  no  gall-stones  ;  adhesions  broken  down. 

After-History. — Good  recovery  ;  jaundice  disappeared  before 
the  patient  returned  home  within  the  month  ;  no  recurrence  of 
rigors. 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Case  264. — Mr.  M.,  aged  fifty-one,  seen  with  Dr.  Ashton  and 
Dr.  Rabagliati,  Bradford.  Indigestion  for  years,  but  pain  at 
lower  part  of  abdomen  for  ten  months;  constipation;  loss  of 
flesh  ;  no  diarrhoea,  but  bleeding  from  rectum  for  some  time  ; 
enlargement  over  the  gall-bladder,  tender;  dilatation  of  the 
stomach  ;  piles  ;  no  stricture  of  rectum  ;  slight  icterus. 

Operation. — 10,6/1899.  Cholecystotomy  ;  distended  gall-bladder 
containing  pus  ;  single  stone  the  size  of  a  hazel-nut  in  distal  end 
of  the  cystic  duct  removed  through  the  gall-bladder ;  drainage. 

After-History. — Good  recovery.     Well  in  1902. 


APPENDIX  383 

Gall-stones  :  Cholecystotomy. 

Case  265. — Mrs.  P.,  aged  fifty-seven,  seen  with  Dr.  McCallum, 
Kendal.  First  attack  of  gall-stone  colic  fourteen  months  ago, 
followed  by  slight  jaundice;  four  attacks  in  June,  1898  ;  respite 
till  December,  when  slight  seizure  ;  four  attacks  since  July  ;  no 
rigors ;  no  jaundice ;  no  tumour ;  tenderness  over  the  gall- 
bladder. 

Operation. — 1 2/5/1 899.  Cholecystotomy;  fifty-two  gall-stones, 
almost  all  small,  removed  from  gall-bladder  ;  drainage  for  one 
week. 

Aftev-Histovy. — Good  recovery. 

Cancev  of  Pancreas,  Great  Pain  :  Cholecystentevostomy . 

Case  266. —  Mr.  L.,  aged  fifty-nine,  seen  with  Dr.  Holloway 
and  Dr.  Bruce,  Birmingham.  Failure  of  health  for  a  year,  but 
otherwise  well  till  six  months  ago ;  since  then  attacks  of  pain, 
beginning  in  lower  abdomen  and  extending  to  the  back  and  upper 
abdomen,  never  to  the  shoulders ;  no  fever  ;  no  rigors  ;  jaundice 
persisted  for  two  months  ;  vomiting,  no  large  quantity,  and  no 
blood  ;  great  loss  of  weight ;  pain  every  twelve  hours,  requiring 
morphia  ;  spare  man,  deeply  jaundiced  ;  pulse  weak,  but  regular  ; 
nodular  swelling,  hard  and  slightly  tender,  in  region  of  the  gall- 
bladder and  towards  the  middle-line  ;  distended  gall-bladder. 

Operation. — 16/5/1899.  Cholecystenterostomy  ;  cancer  of  the 
pancreas  ;  Murphy's  button  used. 

After-History. — Death  ;  cardiac  failure  fourth  day  ;  no  peri- 
tonitis. 

Gall-stones  :  Cholecystotomy. 

Case  267. — Mr.  B.,  aged  forty-eight,  seen  with  Dr.  Mackenzie, 
Burnley.  Five  typical  attacks  of  gall-stone  colic  during  the  last 
six  months,  associated  with  jaundice  ;  no  ague-like  attacks  in  the 
intervals  ;  tenderness  in  the  usual  situation  ;  slight  icteric  tinge  ; 
no  tumour. 

Operation. — 18/5/1899.  Cholecystotomy;  adhesions  around  the 
gall-bladder  separated  ;  several  small  stones  removed  from  the 
gall-bladder,  and  one  large  stone  from  the  cystic  duct  at  the 
junction  with  the  common  duct. 

After-History. — Acute  ether  bronchitis,  followed  by  a  good 
recovery. 

Gall-stones,  Sub-diaphragmatic  Abscess  :  Drainage  of  Abscess ; 

Cholecystotomy. 

Case  268. — Mrs.  W.,  aged  forty-four,  seen  with  Dr.  Lambert, 
Farsley.  Frequent  gall-stone  attacks  for  a  year  or  more,  followed 
by  jaundice,  and  sometimes  by  shivering  attacks.     Of  late  the 


384    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

attacks  occurred  as  often  as  two  or  three  times  a  week  ;  loss  of 
flesh  and  strength  ;  swelling  below  the  right  costal  margin,  with 
marked  tenderness  ;  slight  icteric  tinge,  but  no  marked  jaundice. 

Operation. — 1/6/1899.  Cholecystotomy  ;  gall-bladder  much  con- 
tracted ;  many  adhesions,  during  separation  of  which  pus  escaped 
from  a  small  abscess  cavity  in  the  liver  and  from  between  it  and 
the  diaphragm,  to  which  it  was  adherent ;  several  stones  removed 
from  the  gall-bladder ;  drainage  of  the  gall-bladder  ;  abcess  cavity 
packed  with  iodoform  gauze. 

After-History. — Complete  recovery. 

Mucous  Fistula,  Gall-stones  :  Cholecystotomy. 

Case  269. — Mrs.  W.,  aged  forty-four,  seen  with  Dr.  Mason, 
Leeds.  Cholecystotomy  eighteen  months  before  ;  mucous  fistula 
persisted;  six  weeks  ago  severe  attacks  of  pain;  another  two  weeks 
ago ;  in  latter  a  small  gall-stone  was  passed  through  the  fistula ; 
both  followed  by  jaundice. 

Operation. — 1 5/6/1 899.  Cholecystotomy  ;  sinus  dilated  after 
slight  incision  ;  several  stones  removed  by  forceps ;  drainage. 

After-History. — Good  recovery. 

Jaundice,  Adhesions,  Vertical  Displacement  of  Liver  :  Laparotomy. 

Case  270. — Mrs.  M.,  aged  fifty-two,  seen  with  Dr.  Tyrie, 
Keighley.  History  of  gall-stone  colic ;  attacks  at  intervals  of 
seventeen  years ;  four  in  the  last  month,  usually  followed  by 
jaundice;  ague-like  attacks  recently,  with  loss  of  flesh  and  strength ; 
tenderness  in  the  usual  situation ;  slight  icterus. 

Operation. — 25/5/1899.  Laparotomy.  The  liver  was  found  dis- 
placed vertically,  the  left  lobe  being  high  up  under  the  diaphragm, 
and  the  usual  under-surface  facing  to  the  left.  The  adhesions 
were  so  extensive,  and  the  patient  was  taking  the  anaesthetic  so 
badly — the  pulse  having  gone  up  to  150 — that  I  felt  it  wiser  not 
to  follow  up  the  operation  after  examining  in  the  presumed  posi- 
tion of  the  gall-bladder  and  ducts,  and  not  feeling  any  calculi. 

After-History. — Complete  recovery  followed,  and  after  the  opera- 
tion the  jaundice  cleared,  and  there  were  no  further  attacks  of 
pain  or  fever. 

Gall-stones  in  Common  Duct,  Jaundice,  and  Infective  Cholangitis  : 

(  holcdochotomy. 

Case  271.  Mrs.  A.,  aged  forty-seven,  seen  with  Dr.  Bates, 
Ilkley.  Spasms  for  ten  years;  no  icterus  till  June,  1898,  when 
jaundiced  for  a  week  ;  had  been  jaundiced  off  and  on  since  Christ- 
mas, and  without  intermission  for  two  months  ;  frequent  ague-like 
attacks  and  high  fever  ;  great  loss  of  flesh  ;  slight  bleeding  from 


APPENDIX  385 

the  nose  ;  liver  enlarged,  and  probably  some  enlargement  of  the 
spleen  ;  no  tumour;  tenderness  just  above  the  umbilicus. 

Operation. — 15/6/1899.  Duodeno-choledochotomy  ;  many  old- 
standing  adhesions  of  stomach,  pylorus,  and  colon  to  the  gall- 
bladder and  liver  separated ;  four  floating  gall  stones  removed 
from  the  common  duct  by  an  incision  through  the  duodenum  ; 
little  haemorrhage  ;  calcium  chloride  given ;  drainage  of  right 
kidney-pouch  through  a  counter-opening  at  the  side. 

Aftev-Histovy. — Recovery  ;  December,  1899,  ill  with  cancer  of 
the  liver. 

Gall-stones  :  Cholecystotomy. 

Case  272. — Mr.  G.,  aged  forty-six,  seen  at  the  infirmary. 
Frequent  attacks  of  gall-stone  colic  followed  by  jaundice  ;  attacks 
now  about  twice  a  wreek  ;  slight  icteric  tinge ;  slight  continuous 
pain  over  the  gall-bladder  region,  aggravated  by  pressure  ;  no 
tumour. 

Operation. — 22/6/1899.  Cholecystotomy ;  491  gall-stones  re- 
moved from  the  gall-bladder  and  cystic  duct  down  to  the  common 
duct,  which  was  clear ;  drainage. 

After-History. — Good  recovery. 

Gall-stones,  Cancer  of  Liver,  Infective  Cholangitis  :  Hepatectomy  and 

Cholecystenterostomy. 

Case  273. — Mr.  B.,  aged  forty-six,  seen  with  Dr.  Fisher,  Skip- 
ton.  Gall-stone  attacks  for  seven  years  ;  symptoms  of  floating 
stone  in  common  duct,  1897  '■>  infective  cholangitis,  1899  ;  loss  of 
4  stones  in  weight. 

Operation. — 26/6/1899.  Hepatectomy  and  cholecystenterostomy ; 
tumour  of  liver  found  and  excised  ;  number  of  small  stones  in  the 
common  duct  crushed  ;  Murphy's  button  used. 

After-History. — Good  recovery  ;  rapidly  gained  a  stone  in  weight ; 
well,  1903,  and  of  normal  weight. 

Gall-stones  in  Common  Duct :  Choledochotomy. 

Case  274.  — Mr.  G.,  aged  forty-six,  seen  at  the  infirmary. 
Symptoms  of  gall-stone  colic,  recurring  almost  weekly,  for  nearly 
eleven  months,  each  attack  followed  by  rigors  and  deepening  of 
jaundice,  which  latterly  has  been  persistent ;  great  loss  of  flesh  ; 
liver  moderately  enlarged  ;  irregular  temperature  with  rigors.  No 
enlargement  of  the  gall-bladder  to  be  felt. 

Operation. — 6/7/1899.  Choledochotomy;  single  stone  removed 
from  the  gall-bladder  ;    two  stones  removed  from  the  common 


386    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

duct  through  an  incision  into  the  duct ;  many  adhesions  broken 
down  ;  drainage. 

After-History. — Death ;  persistent  vomiting,  and  death  from 
exhaustion  on  the  fourth  day. 

Gall-stone :  Cholecystotomy. 

Case  275. — Mrs.  J.,  aged  thirty-seven,  seen  with  Dr.  Haswell, 
Penrith.  Cholelithic  attacks  ten  years  off  and  on  ;  less  frequent 
the  last  five  years,  till  January,  1899;  occasional  jaundice  after 
the  seizures ;  loss  of  flesh  ;  tenderness  over  the  gall  -  bladder  ; 
distinct  swelling. 

Operation. — 15/7/1899.  Cholecystotomy;  dilated  gall-bladder; 
single  stone  impacted  in  the  cystic  duct ;  few  adhesions. 

After-History. — Good  recovery. 

Gall-stones,  Cancer  of  Common  Duct :  Cholecystotomy  under  Cocaine. 

Case  276. — Mrs.  B.,  aged  sixty-eight,  seen  at  the  infirmary. 
Spasms  since  adolescence  ;  in  later  years  they  occurred  once  a 
month  ;  before  this  attack  no  jaundice.  Present  illness  began  in 
April  with  a  seizure  like  gall-stone  colic ;  jaundice  at  the  end  of 
a  week,  which  had  persisted  since  ;  tenderness  and  pain  under  the 
right  costal  margin ;  no  rigors  ;  abdomen  distended  ;  no  visible 
peristalsis ;  tumour  hard,  somewhat  irregular,  and  fixed  in  the 
gall-bladder  region  ;  patient  very  much  jaundiced  ;  very  weak  ; 
cardiac  disease. 

Operation. — 20/7/1899.  Cholecystotomy;  gall-bladder  simply 
opened  and  stitched  under  cocaine  ;  no  attempt  made  to  remove 
the  stones  which  were  felt,  as  patient  too  ill. 

After-History. — Death  ;  oozing  from  the  wound  for  two  days ; 
patient  gradually  sank.  Post-mortem  examination  :  Two  large 
stones  in  the  gall-bladder;  at  the  junction  of  the  cystic,  hepatic, 
and  common  ducts  a  cancerous  tumour  about  the  size  of  a  filbert ; 
no  adhesions  ;  duct  completely  occluded ;  no  peritonitis. 

Catarrhal  Cholecystitis,  Dilated  Stomacli :  Cholecystotomy ;  Gastrolysis. 

Case  277. — Mr.  C,  aged  thirty-one,  seen  with  Dr.  Turner, 
York.  Influenza,  February,  1898;  biliary  colic  March  the  same 
year,  with  jaundice;  slight  recurring  attacks  till  January^  1899, 
when  more  severe  attack  with  jaundice  for  six  weeks,  which  com- 
pletely cleared  ;  milder  attacks  since.  For  last  five  months  stomach 
symptoms  most  marked  feature,  and  loss  of  weight  to  the  extent 
of  2  stones  in  sixteen  months  ;  rigid  right  rectus ;  tenderness 
below  the  ninth  costal  cartilage  ;  no  jaundice  ;  dilatation  of  the 
stomach. 

Operation. — 22/8/1899.     Cholecystotomy  ;   detachment  of  adhe- 


APPENDIX  387 

sions ;  markedly  thickened  gall-bladder  ;  inspissated  mucus  ;  no 
gall-stones ;  pylorus  intimately  adherent  to  the  cystic  duct ;  con- 
siderable adhesions  of  stomach  to  the  liver. 

After -History. — Good  recovery.  Served  all  through  the  Boer 
War,  and  was  very  well. 

Recurrent   Pain,   Adhesion,    Catarrhal    Cholecystitis:  Cholecystotomy  ; 

Gastrolysis. 

Case  278. — Mr.  S.,  aged  fifty-one,  seen  with  Dr.  Tait,  Mans- 
field. Distinct  gall-stone  attack  a  year  ago,  not  followed  by 
jaundice  ;.  since  then  a  seizure  each  month  ;  twice  jaundiced  ;  the 
pain  always  passes  to  the  right  shoulder-blade,  though  there  is 
considerable  stomach  trouble  ;  loss  of  weight,  3  stones ;  tender- 
ness over  the  gall-bladder  ;  no  tumour. 

Operation. — 24/8/1899.  Cholecystotomy;  very  extensive  adhe- 
sions of  stomach  and  colon  to  the  gall-bladder,  liver,  and  anterior 
abdominal  wall ;  pylorus  adherent  to  the  cystic  duct ;  gall-bladder 
very  much  thickened  and  shrunken,  containing  inspissated  mucus; 
no  gall-stones  ;  drainage  for  ten  days. 

After-History. — Good  recovery. 

Gall-stone  in  Common  Duct,  Jaundice  :  Choledochotomy  ;  Hcumatcmcsis. 

Case  279. — Mrs.  K.,  aged  forty-nine,  seen  with  Dr.  Fisher, 
Skipton.  Gall-stone  attack  followed  by  jaundice  twelve  years 
ago  ;  freedom  from  severe  seizures  for  ten  years,  but  had  spasms 
and  painful  digestion  ;  several  attacks  since  ;  marked  loss  of  flesh  ; 
dilatation  of  the  stomach  well  marked ;  hard  swelling  felt  beneath 
the  ribs  ;  slight  icterus  ;  albuminuria. 

Operation. — 6/9/1899.  Choledochotomy  ;  numerous  adhesions 
separated ;  gall-bladder  contracted ;  common  duct  as  large  as 
small  intestine ;  duct  incised,  and  two  gall-stones  size  of  small 
Brazil  nuts  removed  ;  duct  sutured  ;  lumbar  drainage. 

After-History. — Violent  haematemesis  twelve  hours  after  opera- 
tion, and  death  from  exhaustion  within  thirty  hours.  No  signs  of 
peritonitis  or  of  bleeding  other  than  gastric. 

Gall-stones,  Distended  Gall-bladder  :  Cholecystotomy. 

Case  280. — Mrs.  M.,  aged  thirty-seven,  seen  with  Dr.  Murphy, 
Leeds.  History  of  spasms  for  ten  years,  much  more  frequent 
during  the  past  twelve  months  ;  distended  gall  bladder  with  con- 
stant pain  for  six  months  ;  great  loss  of  flesh  ;  no  jaundice. 

Operation. — 24/8/1899.  Cholecystotomy  ;  distended  gall-bladder 
containing  cloudy  mucus  ;  one  small  and  two  large  calculi  re- 
moved from  the  cystic  duct  through  an  incision  in  the  gall-bladder; 
drainage. 

After-History. — Good  recovery. 

25—2 


388    DISEASES  OE  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones,    Empyema    of  Gall-bladder,   Dilatation   of  Stomach  : 
Cholecystotomy ;   Gastrolysis. 

Case  281.  —Mrs.  I.,  aged  sixty-two,  seen  with  Prof.  C.  J.  Wright, 
Leeds,  and  Dr.  Starling,  Tunbridge  Wells.  Gall-stone  symptoms 
for  years ;  seen  a  year  ago  and  operation  urged  ;  rigors  and  deepen- 
ing of  the  jaundice  during  year  before  operation,  with  great  loss 
of  flesh  ;  dilatation  of  the  stomach. 

Operation. — 2 1/9/ 1899.  Cholecystotomy;  2  ounces  of  pus  in 
the  gall-bladder,  which  was  firmly  adherent  to  the  colon  and 
stomach  ;  one  large  stone  removed  from  the  gall-bladder,  and  two 
larger  ones  from  the  cystic  duct ;  at  the  site  of  impaction  of  the 
lowest  stone  there  was  thickening  of  the  duct,  probably  inflam- 
matory ;  stomach  much  dilated  ;  pylorus  kinked. 

After-History. — Uninterrupted  recovery. 

Chronic  Pancreatitis,  Jaundice  :  Cholecystotomy. 

Case  282. — Emma  W.,  aged  thirty-five,  seen  at  the  Leeds 
General  Infirmary.  Attacks  of  pain  in  the  upper  abdominal 
region  for  twelve  years ;  lately  they  had  become  more  frequent. 
The  seizures  began  with  pain  in  the  epigastrium,  accompanied  by 
cold  sweats  and  faintness  ;  jaundice  followed,  and  was  intensified 
by  each  attack.  No  swelling  of  the  liver  or  gall-bladder  to  be  made 
out  on  admission. 

Operation. — 2 1/9/ 1899.  Cholecystotomy  ;  thickened  gall-bladder, 
but  no  gall-stones  ;  the  lower  part  of  the  common  duct  was  over- 
laid and  compressed  by  a  well-marked  swelling  of  the  pancreas, 
which  was  hard  (chronic  pancreatitis). 

After-History. — Recovery. 

Gall-stones  :  Cholecystotomy. 

Case  283. — Margaret  F.,  aged  forty-four,  seen  at  the  Leeds 
General  Infirmary.  For  twelve  months  had  had  frequent  attacks 
of  biliary  colic,  accompanied  by  jaundice,  and  lately  the  patient 
had  never  been  free  from  pain. 

Operation. — 28/9/1899.  Cholecystotomy;  gall-bladder  distended, 
containing  four  calculi. 

After- History. — The  patient  made  a  good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  284. — Mrs.  R.,  aged  forty-five,  seen  with  Dr.  Greig. 
Cholelithic  attacks  for  twenty-four  years  ;  at  first  no  jaundice,  but 
latterly  after  each  attack  ;  recent  attacks  more  severe ;  some  loss 
of  flesh ;  dilatation  of  the  stomach  ;  tenderness  1  inch  to  the 
right  of  and  above  the  umbilicus  ;  no  enlargement  of  the  gall- 
bladder or  liver. 


APPENDIX  389 

Operation. — 14/10/1899.  Cholecystotomy  ;  twenty-eight  stones 
removed  from  the  gall-bladder ;  cystic  duct  found  strictured ; 
adhesions  separated  ;  drainage,  twelve  days. 

Aftev-Histovy. — Good  recovery,  but  slight  attack  of  pain  one 
month  after  operation,  probably  from  the  passage  of  inspissated 
mucus;  January  28, 1900,  had  had  no  further  trouble;  felt  very  well. 

Chronic  Pancreatitis,  Jaundice  :  Cholecystenterostomy. 

Case  285. — Mrs.  H.,  aged  fifty-one,  seen  with  Dr.  Squance, 
Sunderland.  Attacks  of  cholelithiasis  for  three  years  ;  during  the 
past  fourteen  weeks  attacks  frequent  and  severe,  and  jaundice 
practically  continuous ;  loss  of  flesh  ;  no  rigors ;  no  tumour 
noticed  ;  no  enlargement  of  the  gall-bladder  or  liver  ;  tenderness 
in  the  epigastrium  ;  slight  jaundice;  slight  albuminuria  ;  no  oedema 
of  the  feet. 

Operation. — 23/10/1899.  Cholecystenterostomy;  fifteen  gall- 
stones removed  from  the  gall-bladder  ;  large  mass,  nodular  and 
hard  at  the  head  of  the  pancreas  ;  Murphy's  button  used  to  join 
the  gall-bladder  to  the  duodenum. 

After-History. — Very  good  recovery  ;  improvement  immediate. 
Tumour  ;  chronic  pancreatitis ;  within  two  months  had  gained 
10  pounds  in  weight ;  well  in  1903. 

Cancer  of  Gall-bladder  :  Cholecystectomy. 

Case  286. — Mr.  W.,  aged  forty-eight,  seen  with  Dr.  Wilson, 
Paddock.  For  over  ten  years  spasms  at  intervals  of  one  to  three 
months  ;  latterly  they  occurred  every  week  ;  now  constant  pain  ; 
continuous  jaundice  for  six  weeks ;  bad  colour  for  a  year ;  no 
rigors ;  lost  2  stones  4  pounds  since  June.  Enlargement  of  the 
right  lobe  of  the  liver,  and  probably  of  the  gall-bladder  ;  tender- 
ness over  the  gall-bladder  and  common  duct ;  jaundice  and  albu- 
minuria. 

Operation. — 30/10/1899.  Cancer  of  the  gall-bladder  and  cystic 
duct ;  cholecystectomy  and  ligature  of  the  cystic,  close  to  the 
common  duct. 

After-History. — Good  recovery  ;  January,  1900,  report  to  say 
patient  feeling  well  and  improving  every  day. 

Chronic  Pancreatitis,  with  Gall-stone  in  the  Common  Bile-duct,  Sup- 
purative Cholangitis,  Abscess  of  Liver:  Cholecystenterostomy. — 
Relief;  Relapse. 

Case  287. — Mr.  J.  F.,  aged  forty-five,  residing  at  Queensbury, 
was  admitted  into  the  Leeds  General  Infirmary  under  my  care  on 
November  3,  1899,  suffering  from  jaundice,  with  repeated  attacks 
of  pain  and  ague-like  seizures.     He  bad  been  well  up  to  thirteen 


3QO    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

months  before  his  admission,  when  the  attacks  began,  and  since 
their  onset  he  had  lost  6  stones  in  weight.    Jaundice  followed  the 
first  seizure  and  persisted,  but  after  each  attack  of  pain  it  was 
more  intense.     He  was  so   weak  and  ill  that  it  was  feared  he 
could  not  bear  an  operation.    An  enlargement  of  the  right  lobe  of 
the  liver  could  be  felt,  and  on  its  inner  side  in  the  mid-line  just 
above  the  umbilicus  there  was  another  tumour  situated  behind 
the  stomach.     On  November  9  an  operation  was  performed  on  a 
heated  table  with  the  patient  enveloped  in  wool,  an  injection  of 
10  minims  of  solution  of  strychnia  having  been  previously  given. 
On  opening  the  abdomen,  an  enlargement  of  the  right  lobe  of  the 
liver   was    seen,    the    gall  -  bladder    was    found    shrunken    under 
adhesions,  a  floating  gall-stone  too  hard  to  crush  was  felt  in  the 
common   duct,  and   a  hard  nodular  tumour  of  the   head   of  the 
pancreas    was    discovered.      As   the    latter    was   thought   to   be 
malignant  and  the  patient  was  extremely  feeble,  choledochotomy 
was  not  performed,  but  the  gall-bladder  was  connected   to  the 
duodenum  by  a  Murphy's  button  in  order  to  give  temporary  relief 
to  the  jaundice,  fever,  and  pain.     He  had  a  severe  rigor  on  the 
night  of  operation,  but  afterwards  progressed  satisfactorily,  and 
recovered  from  the  operation.     The  button  passed  on  the  twelfth 
day,  and  as  he  had  gained  some  weight  and  was  taking  his  food 
well,  it  was  thought  that  the  operation  was  going  to  be  of  real 
benefit   to   him.      The    subsequent    history  of  the  case  was   as 
follows :  On  December  8  (a  month  and  a  day  after  operation)  he 
had  a  feeling  of  chilliness,  and  a  temperature  of  1010  F.  followed 
for  two  days,  his  temperature  being  afterwards  normal  for  twelve 
days,  when  he  had  a  rigor  and  a  return  of  the  jaundice.     From 
this  time,  although  he  got  up  every  day,  he  gradually  became 
weaker,  and  in   January,   1900,   he  developed   bronchitis,  which 
ushered  in  the  final  scene.     At  the  post-mortem  examination  the 
peritoneum  was  found  to  be  free  from  inflammation,  and  the  gall- 
bladder was  found  to  be  connected  to  the  duodenum  1^  inches 
beyond  the  pylorus,  but  the  opening  had  contracted   so  that  it 
would  only  admit  a  fine   probe.      The  common  bile-duct   was 
dilated  and  ulcerated,  and  it  contained  a  gall-stone  of  the  size  of  a 
filbert.     The  liver  was  considerably  enlarged,  and  the  right  lobe 
was  occupied  by  an   abscess  containing  thick,  slimy   muco-pus. 
The  walls  of  the  abscess  cavity  were  ragged  and  ill-defined,  and 
it  reached  nearly  to  the  surface  both  in  front  and  behind.     It  was 
doubtless  the  result   of  the  suppurative  cholangitis  which   was 
present.     The  pancreas  was  much  indurated  about  the  head,  and, 
together  with  the  indurated  tissues  in  the  small  omentum,  pre- 
sented on  palpation  the  sensation  of  a  tumour.     On  section  it 
presented  to  the  naked  eye  the  appearance  of  chronic  inflammation 


APPENDIX  391 

rather  than  growth,  and  on  microscopical  examination  this  view 
was  confirmed,  there  being  a  great  excess  of  interstitial  fibrous 
tissue,  but  no  sign  of  cancer. 

Suppurative  Cholangitis,  Gall-stones  in  Common  Duct  :  Duodeno- 
Choledochotomy :  Duodenal  Fistula. 

Case  288. — Mrs.  F.,  sequel  of  Case  37,  operated  on  in  1891, 
when  gall-stones  were  crushed  in  the  common  duct.  She  made 
a  good  recovery  from  the  operation,  and  was  well  for  some  time  ; 
but  in  1896  the  symptoms  recurred,  associated  with  jaundice,  due 
probably  to  the  fragments  that  had  been  left.  Her  attacks  of 
pain  were  associated  with  an  intensification  of  the  jaundice,  and 
with  frequent  ague-like  seizures  pointing  to  suppurative  cholan- 
gitis, and  a  further  operation  was  performed. 

Operation. — 23/7/1900.  Adhesions  were  most  extensive,  and 
occupied  along  time  in  detaching.  The  cystic  and  common  ducts 
were  each  thickened,  and  contained  fragments  of  gall-stones  and 
purulent  bile.  The  head  of  the  pancreas  was  hard  and  pressing 
on  the  duct.  Duodeno-choledochotomy  was  performed,  the  wound 
being  afterwards  sutured  with  catgut.  Although  she  suffered  from 
shock  for  a  few  hours  after  the  operation,  yet  she  rallied  well  and 
appeared  to  be  going  on  satisfactorily.  At  the  end  of  a  week  a 
duodenal  fistula  developed,  which  rendered  feeding  extremely 
difficult,  and  led  to  death  from  exhaustion  a  week  later. 

Gall-stones,  Tumour  of  Head  of  Pancreas,  Chronic  Pancreatitis  : 

Cholecystotomy. 

Case  289. — Mrs.  R.,  aged  forty-two,  seen  with  Dr.  Rayner, 
Stockport.  Spasms  fifteen  years,  much  worse  lately  ;  for  the  last 
three  years  accompanied  by  jaundice  ;  latterly  the  jaundice  had 
been  persistent  ;  a  rigor  with  the  last  attack ;  no  ascites  ;  no 
oedema  of  the  legs  ;  gall-bladder  not  enlarged ;  no  nodules  on  the 
liver  ;  patient  very  feeble  ;  pulse  120. 

Operation. — 18/11/1899.  Cholecystotomy;  adhesion  of  the  gall- 
bladder to  the  liver,  stomach,  colon,  and  omentum  ;  tumour  of 
the  head  of  the  pancreas,  nodular  in  character  ;  a  large  gall-stone 
at  the  junction  of  the  cystic  and  common  duct  removed  through 
the  gall-bladder;  many  small  calculi.  At  the  end  of  the  operation 
the  pulse  was  too;  10  minims  of  liq.  strychninae  given  before 
operation. 

After-History. — Good  recovery  ;  January,  1900,  patient  said  to 
be  very  well. 

Gall-stones :  Cholecystotomy. 

Case  290. — Mrs.  S.,  aged  forty-six,  seen  with  Dr.  Woodcock, 
Leeds.     Twenty-three  years  ago  had  spasms,  then  free  till  three 


392    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

years  ago  ;  since  then  frequent  gall-stone  colic  at  intervals  of  one 
to  three  weeks.  Never  deeply  jaundiced,  but  considerable  loss  of 
weight ;  no  tumour ;  a  slight  tinge  of  jaundice  present ;  tender- 
ness over  the  gall-bladder. 

Operation.  —  24/11/1899.  Cholecystotomy  ;  eighty  gall-stones 
removed  ;  numerous  adhesions  separated. 

After-History. — Good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  291. — Mrs.  L.,  aged  sixty-two,  seen  with  Dr.  Spink, 
Otley.  Movable  tumour  in  abdomen  noticed  five  years  ago  ; 
spasms  twenty  years  ago,  not  lately  ;  constipation  for  years ;  no 
loss  of  flesh  ;  no  vomiting  ;  movable  smooth  tumour  to  right  of 
and  below  the  umbilicus,  free  from  the  kidney,  which  was  normal, 
but  continuous  with  Riedel's  lobe. 

Operation. — 30/11/1899.  Cholecystotomy;  single  large  stone 
removed  from  the  gall-bladder. 

After-History. — Good  recovery. 

Empyema  of  Gall  bladder  bursting  into  Sac  of  Umbilical  Hernia, 
Gall-stones :  Cholecystotomy. 

Case  292. — Mrs.  P.,  aged  seventy,  seen  with  Dr.  Shann,  York. 
Seen  for  what  was  supposed  to  be  incarcerated  hernia  becoming 
strangulated.  Fell  downstairs  eighteen  months  ago,  since  which 
symptoms  marked,  and  it  was  thought  that  some  fibres  of  the 
rectus  had  been  ruptured  ;  history  of  spasms  with  jaundice  years 
ago ;  hard  tender  lump  above  the  umbilicus  said  to  have  been 
partly  reducible  with  a  gurgle  till  twenty-four  hours  before. 

Operation. — 4/ 12/ 1899.  Cholecystotomy  ;  on  opening  the  sac, 
muco-pus  with  gall-stones  found ;  opening  enlarged  and  large 
calculus  removed  from  the  gall-bladder  ;  drainage. 

After-History. — Complete  recovery  ;  report,  January  2,  1900,  to 
say  the  patient  was  quite  well. 

Gall-stones :  Cholecystotomy. 

Case  293. — George  W.,  aged  sixty-two,  seen  at  the  Leeds 
General  Infirmary.  For  twenty  years  had  had  occasional  attacks 
of  biliary  colic,  and  six  months  before  admission  had  a  very  severe 
attack,  followed  by  peritonitis.  There  had  been  no  jaundice  and 
no  enlargement  of  the  gall-bladder  or  liver  ;  some  tenderness  at 
the  umbilicus. 

Operation. — 1/12/1899.  Cholecystotomy;  285  gall-stones  re- 
moved from  the  gall-bladder  and  cystic  duct. 


A  PPENDIX  393 

After -History.  —  Patient  was  quite  well  for  three  weeks, 
when  he  was  suddenly  seized  with  vomiting,  and  collapsed 
the  next  day.  At  the  autopsy  no  peritonitis  was  found,  nor  any- 
thing abnormal  in  connection  with  the  operation,  but  two  gall- 
stones had  apparently  descended  from  the  liver  and  become 
impacted  in  the  common  duct.  These  were  doubtless  the  cause 
of  the  vomiting  and  collapse. 

Gall-stone  impacted  in  the  Cystic  Duct :  Cholcdochotomy  and 
Cholecystotomy. 

Case  294. — Ellen  W.,  aged  forty-nine,  seen  at  the  Leeds 
General  Infirmary.  Twelve  months  previously  she  had  a  severe 
attack  of  biliary  colic,  followed  by  peritonitis.  The  pains  had 
been  frequent  since,  and  about  six  months  before  admission  a 
swelling  was  noticed  in  the  abdomen.  She  had  lost  weight  and 
was  rather  feeble.  The  liver  was  somewhat  enlarged,  and  below 
it  the  gall-bladder  could  be  felt  as  a  nodular  swelling.  No 
jaundice. 

Operation. — 7/12/1899.  One  stone  impacted  in  the  cystic  duct 
could  not  be  pushed  up  into  the  gall-bladder,  and  was  removed 
through  an  incision  in  the  duct ;  catarrh  of  the  gall-bladder, 
which  was  drained. 

After-History. — Patient  made  a  good  recovery. 

Spasms,  Catarrhal  Cholecystitis,  Dilated  Stomach  :  Gastrolysis. 

Case  295. — Mr.  D.,  aged  forty-nine,  seen  with  Dr.  McGregor 
Young,  Leeds.  Cholecystitis  after  influenza  two  years  ago ; 
during  the  past  year  he  had  had  indigestion  and  loss  of  weight  ; 
one  year  ago  he  weighed  14  stones,  now  12  stones.  No  albumin, 
no  sugar  ;  rigid  right  rectus  simulating  tumour ;  dilatation  of  the 
stomach. 

Operation.  —  7/ 12/1899.  Separation  of  adhesions;  intimate 
adhesion  between  the  pylorus  and  stomach  and  the  liver  and  gall- 
bladder ;  no  gall-stones  ;  adhesions  separated. 

After-History. — January  12,  1900,  had  gained  10  pounds  in 
weight;  January  22,  gained  4  pounds  more. 

Chronic  Pancreatitis,  Empyema  of  Gall-bladder,  Gall-stones  : 

Cholecystotomy. 

Case  296. — Mrs.  D.,  aged  forty-six,  seen  with  Dr.  Berry, 
Keighley.  Spasms  for  years;  acute  seizure  in  July,  and  three 
times  since ;  since  July  pain  and  sickness  every  two  weeks.  No 
tumour  felt  at  any  time ;  occasionally  after  an  attack  slight 
jaundice ;    lost    1    stone    in    weight  ;    never   vomited    blood ;    no 


394    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

melaena  ;  tenderness  over  gall-bladder  ;  no  tumour  ;  slight  enlarge- 
ment of  the  head  of  the  pancreas. 

Operation.  — 11/12/1 899.  Cholecystotomy  ;  empyema  of  the 
gall-bladder ;  many  stones  removed  from  the  gall-bladder  and 
cystic  duct ;  adhesions  broken  down  ;  nodular  condition  of  the 
head  of  the  pancreas  ;  chronic  pancreatitis. 

After-History. — Good  recovery  ;  well,  1901. 

Gall-stones,  Empyema  of  Gall-bladder  :  Cholecystotomy. 

Case  297. — Mrs.  F.,  aged  fifty-four,  seen  with  Dr.  Marsden, 
Burnley.  Cholelithic  colic  for  sixteen  years ;  at  first  three  or 
four  times  a  year  ;  for  last  three  years  constant  discomfort,  with 
severe  colic  every  five  weeks.  No  jaundice ;  lying  on  the  right 
side  easier  than  the  left ;  tenderness  below  the  right  costal  margin 
at  the  ninth  costal  cartilage  ;  rigidity  of  the  right  rectus ;  no 
tumour. 

Operation. — 21/12/1899.  Cholecystotomy;  gall-bladder  acutely 
inflamed  and  containing  pus  ;  two  large  stones  removed  from  the 
cystic  duct. 

After-History. — Complete  recovery. 

Gall-stones :  Cholecystotomy. 

Case  298. — Mrs.  M.,  aged  forty-four,  seen  with  Dr.  Veale, 
Drighlington.  Cholelithiasis  four  years,  with  repeated  typical 
attacks  requiring  morphia  to  subdue  the  pain  ;  three  attacks  within 
the  last  fortnight ;  no  jaundice ;  no  tumour,  but  tenderness  over 
the  gall-bladder  region. 

Operation.— 21/18/1899.  Cholecystotomy;  gall-bladder  high  up 
under  the  liver  ;  large  stone  in  the  cystic  duct  pushed  back  and 
removed,  along  with  fifty  gall-stones  from  the  gall-bladder. 

After-History. — Complete  recovery. 

Gangrene  of  G all-Bladder  :  Cholecystectomy  and  Cholecystotomy. 

Case  299. — Mr.  A.,  aged  fifty-five,  seen  with  Dr.  Tempest 
Anderson,  York.  No  history  of  gall-stone  colic  till  the  beginning 
of  December,  1899,  when  severe  attack,  without  jaundice;  two 
minor  attacks  since  ;  severe  seizure  a  week  ago,  with  rigor  and 
elevated  temperature,  which  had  persisted  since  ;  no  jaundice  ; 
very  great  tenderness  over  the  gall-bladder  and  the  whole  of  the 
right  hypochondrium  ;  rigid  right  rectus  and  questionable  distended 
gall-bladder. 

Operation. — 10/1/1900.  Partial  cholecystectomy  and  chole- 
cystotomy ;  no  gall-stones,  but  very  marked  local  peritonitis  ;  distal 


APPENDIX  395 

half  of  the  gall-bladder,  which  was  gangrenous,  excised  ;  remnant 
of  cyst  drained. 

After-History. — Complete  recovery. 

Gall-stones,  Dilated  Stomach  :  Cholecystotomy  ;  Gastrolysis. 

Case  300.  — Mrs.  M.,  aged  sixty-two,  seen  with  Dr.  Humphery, 
Armley.  Subject  to  epigastric  and  right  hypochondriac  pain  for 
two  years;  worse  since  an  attack  of  influenza  in  1898;  attacks  of 
pain  at  times  very  severe,  but  never  followed  by  jaundice ;  flatu- 
lent distension  and  indigestion,  with  vomiting  at  times,  and  in- 
ability to  take  solid  food  for  six  months  before  operation  ;  tumour 
beneath  the  right  costal  margin  noticed  for  four  months,  and 
tenderness  between  the  umbilicus  and  ninth  costal  cartilage  ; 
stomach  splash  obtained  ;  bedridden  for  two  months  before  opera- 
tion ;  great  loss  of  flesh. 

Operation. — 10/1/igoo.  Cholecystotomy;  adherent  pylorus  freed ; 
two  large  gall-stones  removed  from  the  cystic  duct,  and  numerous 
small  calculi  from  the  gall-bladder. 

After-History. — Complete  recovery  ;  able  to  take  any  kind  of 
food,  and  now  putting  on  flesh ;  well,  1902. 

Gall-stones,  Dilated  Stomach,  Adhesions  :  Cholecystotomy  ;  Gastrolysis. 

Case  301. — Miss  T.,  aged  thirty-two,  seen  with  Dr.  Moffatt, 
Keighley.  Attacks  of  epigastric  pain  for  four  years,  occurring  at 
first  every  three  months,  but  later  more  frequently  ;  vomiting  and 
shivering  with  each  attack,  but  never  definite  jaundice  ;  painful 
seizures  have  no  relation  to  taking  food  or  exertion.  Tenderness 
over  the  gall-bladder;  no  tumour;  no  jaundice  ;  stomach  dilated 
moderately. 

Operation. — 13/1/1900.  Cholecystotomy;  one  gall-stone  the  size 
of  a  cherry  and  424  small  stones  removed  from  the  gall-bladder 
and  cystic  duct  ;  pylorus,  which  was  closely  adherent  to  the  gall- 
bladder and  duct,  freed. 

After-History. — Good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  302.— Mrs.  S.,  aged  thirty-five,  seen  at  the  infirmary. 
Severe  attacks  of  cholelithic  colic,  and  many  slight  attacks  during 
the  last  five  years,  each  attack  followed  by  more  or  less  jaundice; 
eleven  years  ago  slight  attacks  of  spasms  with  jaundice.  Slight 
tenderness  on  deep  palpation  over  the  gall  bladder  ;  slight  jaundice ; 
no  other  physical  signs. 

Operation. — 13/1/1900.  Cholecystotomy;  229  small  stones  re- 
moved from  the  gall-bladder  and  cystic  duct,  which  wras  dilated. 

After-History. — Good  recovery. 


396    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

Gall-stones :  Cholecystotomy. 

Case  303. — Mrs.  S.,  aged  fifty-four,  seen  at  the  infirmary.  For 
twelve  months  repeated  slight  attacks  of  spasms ;  during  the  last 
three  months  the  attacks  had  been  much  more  severe.  Three 
weeks  ago,  after  an  attack,  the  patient  passed  four  small  gall- 
stones per  rectum ;  following  this  there  was  some  melaena ;  distended 
gall-bladder ;  no  jaundice. 

Operation. — 18/1/1900.  Cholecystotomy;  two  large  gall-stones 
removed  from  the  gall-bladder,  one  ^  inch  in  diameter,  and 
another  f  inch  in  diameter. 

After-History. — Good  recovery. 

Gall-stone  in  Common  Died,  Fistula  between  Gall-bladder  and  Colon  : 
Choledochotomy  ;  Closure  of  Fistula. 

Case  304. — Mr.  G.,  aged  fifty,  seen  with  Dr.  W.  No  history 
of  spasms;  first  attack  of  gall-stone  colic  in  October,  1897,  followed 
by  jaundice;  severe  seizures  in  December,  1897,  with  jaundice 
lasting  two  months,  and  associated  with  ague-like  seizures ;  slight 
attacks  for  a  year,  and  then  one  very  severe  in  December,  1898, 
and  again  in  January,  1899.  During  the  whole  of  the  period  the 
icterus  deepened  after  each  attack,  and  occasionally  rigors  occurred; 
lost  over  i\  stones  in  weight ;  jaundiced,  but  not  deeply  ;  liver  not 
enlarged  ;  no  tumour  of  the  gall-bladder  ;  tenderness  above  and  to 
the  right  of  umbilicus  ;  well-marked  dilatation  of  the  stomach. 

Operation. — 28/1/1900.  Fistula  between  shrunken  gall-bladder 
and  colon  discovered ;  cystic  duct  shrunken  ;  common  duct  dilated 
to  size  of  small  intestine,  and  containing  large  floating  gall-stone. 
An  incision  was  continued  down  the  shrunken  cystic  duct  until  it 
reached  the  dilated  common  duct ;  a  gall-stone  was  crushed,  and 
fragments  manipulated  back  through  the  cystic  duct ;  tube  intro- 
duced into  common  duct  through  cystic  duct ;  fistulous  opening 
into  colon  closed. 

After-History. — Uninterrupted  recovery. 

Catarrhal  Cholecystitis  :  Cholecystotomy  ;  Gastrolysis. 

Case  305. — Mrs.  W.,  aged  thirty-eight,  seen  with  Dr.  Wallis, 
Barnsley.  For  twelve  years  hepatic  colic,  but  pain  rather  irregular, 
passing  to  the  groin  as  well  as  to  the  shoulder  ;  latterly  the  attacks 
of  pain  had  recurred  every  two  or  three  months ;  patient  had  never 
been  jaundiced  ;  no  physical  signs. 

Operation. — 6/2/1900.  Cholecystotomy  and  separation  of  adhe- 
sions ;  inspissated  bile-stained  mucus  in  the  gall-bladder  ;  intimate 
adhesions  of  the  stomach  to  the  liver  and  gall-bladder  ;  drainage 
of  the  cyst  and  separation  of  adhesions. 

After-History. — Good  recovery. 


APPENDIX  397 

Catarrhal  Cholecystitis,  Pyloric  Adhesions  :  Cholecystoiomy  ; 

Gastrolysis. 

Case  306. — Mrs.  M.  P.,  aged  thirty,  seen  with  Dr.  Rodgers, 
Burnley.  Gall-stone  attacks  for  twelve  years ;  recently  more 
frequent  and  severe,  so  that  she  had  been  off  work  for  several 
months  ;  dyspepsia  and  some  loss  of  flesh  ;  no  rigors  ;  no  jaundice  ; 
no  tumour. 

Operation. — 7/2/1900.  Cholecystotomy  ;  thick  mucus,  but  no 
gall-stones ;  pylorus  adherent  to  the  cystic  duct,  with  kinking  of 
the  first  part  of  the  duodenum  ;  adhesions  separated  ;  gall-bladder 
drained. 

After-History. — Good  recovery. 

Cancer  of  Pancreas  :  Cholecystenterostomy. 

Case  307. — Mr.  W.,  aged  fifty-six,  seen  with  Dr.  Mercer,  Brad- 
ford. Fourteen  years  ago  the  patient  began  to  suffer  from  attacks 
of  biliary  colic,  and  five  years  later  three  operations  were  per- 
formed by  another  surgeon  and  stones  removed.  He  was  well 
up  to  six  months  ago,  when  the  pain  recurred  with  chronic  jaun- 
dice and  great  loss  of  flesh  and  strength. 

Operation. — 7/2/1900.  Cholecystenterostomy;  Murphy's  button 
used  ;  cancer  of  the  pancreas  ;  no  gall-stones  found. 

After-History. — Death  ten  days  after  operation  from  persistent 
vomiting  and  exhaustion  ;  no  autopsy. 

Catarrhal  Cholecystitis,  Adhesions:  Cholecystotomy ;  Gastrolysis. 

Case  308. — Mr.  W.,  aged  forty,  seen  with  Dr.  Bradley,  Bentham. 
For  six  years  subject  to  attacks  of  pain  in  the  epigastrium,  followed 
by  vomiting  ;  lately  the  attacks  more  frequent.  Discoloration  of 
urine  ;  loss  of  weight. 

Operation. — 1 6/2/1  goo.  Cholecystotomy;  firm  adhesions  between 
pylorus,  colon,  gall-bladder,  and  liver  separated ;  no  gall-stones 
found  ;  catarrh  of  the  gall-bladder. 

After-History. — Good  recovery. 

Gall-stones,  Cancer  of  Gall-bladder  with  Suppuration :  Cholecystotomy. 

Case  309. — Jane  A.,  aged  forty-three,  seen  at  the  Leeds  General 
Infirmary.  For  some  months  the  patient  had  had  pain  in  the 
upper  abdomen;  four  months  ago  she  had  an  attack  of  acute  colic, 
and  since  then  the  attacks  had  come  every  two  or  three  days, 
and  had  been  followed  by  jaundice ;  shivering  attacks  had  been 
frequent. 

Operation. — 1 8/2/1 900.  Cholecystotomy;  the  gall-bladder  con- 
tained pus  and  gall-stones  ;  it  was  much  thickened,  and  apparently 
infiltrated  with  malignant  disease.    After  the  operation  a  quantity 


398    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

of  pus  continued  to  be  discharged  from  the  gall-bladder,  and  the 
patient's  condition  became  so  much  improved  that  the  diagnosis 
of  cancer  became  doubtful.  She  returned  home  with  a  fistula, 
but  much  relieved.     (See  Case  334.) 

Gall-stones  in  Common  Duct,  Jaundice,  Infective  Cholangitis  :  Chole- 
cystotomy.      Patient  too  ill  for  an  Extensive  Operation. 

Case  310. — Hannah  K.,  aged  fifty-three,  admitted  to  the  Leeds 
General  Infirmary,  February  20,  1900.  Two  and  a  half  years 
ago  the  patient  had  had  an  acute  illness  with  severe  abdominal 
pain,  vomiting,  constipation,  and  swelling  in  the  upper  part  of  the 
abdomen  ;  there  was  no  jaundice.  Patient  recovered,  but  had  a 
similar  attack  six  months  afterwards,  followed  by  jaundice,  which 
had  persisted  up  to  admission  ;  since,  she  had  had  minor  attacks 
of  pain,  and  lately  the  attacks  had  become  more  severe,  and  the 
jaundice  had  become  more  intense ;  there  had  been  great  loss  of 
weight ;  the  liver  was  enlarged,  and  the  gall-bladder  distended  and 
extremely  tender. 

Operation. — 2/3/1900.  Cholecystotomy ;  two  small  stones  re- 
moved ;  the  common  duct  was  felt  to  be  full  of  stones,  and  an 
attempt  to  manipulate  these  back  into  the  gall-bladder  was  un- 
successful ;  as  the  duct  was  high  up  under  the  liver,  and  the 
patient's  condition  extremely  bad,  choledochotomy  was  not  per- 
formed ;  a  large  tube  was  put  in  the  gall-bladder,  and  the  wound 
was  closed  in  the  usual  way. 

After-History. — The  patient  recovered  from  the  operation,  and 
the  wound  healed.  She  appeared  to  be  doing  well  for  a  while,  but 
gradually  became  weaker,  and  died  on  March  25  from  exhaustion. 

Gall-stones :  Cholecystotomy. 

Case  311. — Alice  P.,  aged  forty,  admitted  to  the  General 
Infirmary,  March  13,  1900.  Ten  years  ago  the  patient  com- 
menced to  have  attacks  of  biliary  colic  ;  she  had  been  free  from  pain 
for  a  considerable  time  up  to  eighteen  months  ago,  when  the 
attacks  recurred  with  increasing  severity,  and  were  followed  by 
jaundice  ;  on  one  occasion  gall-stones  were  found  in  the 
motions.  On  admission  there  was  no  jaundice  ;  no  enlargement  of 
the  gall  bladder,  but  considerable  tenderness  on  palpation. 

Operation. — 22/3/1900.  Cholecystotomy;  one  large  and  several 
small  stones  removed  from  the  gall-bladder. 

After-History. — Patient  made  a  good  recovery. 

Gall  stones,  Jaundice,  Infective  Cholangitis  :  Cholecystotomy. 

Case  312. — Mrs.  F.,  seen  with  Dr.  Bradbury,  Cambridge.  For 
ten  years  subject  to  attacks  of  painful  indigestion  ;  five  months 


APPENDIX  y/) 

ago  a  severe  attack  of  pain  accompanied  by  jaundice,  since  which 
time  she  had  never  been  free  from  it ;  number  of  small  gall- 
stones had  been  passed  in  the  motions ;  great  loss  of  flesh  with 
irregular  fever. 

Operation. — 27/3/1900.  Cholecystotomy  ;  607  gall-stones  re- 
moved, some  from  cavity  in  the  wall  of  the  cystic  duct. 

After-History. — Good  recovery,  but  convalescence  prolonged 
by  some  chest  trouble  ;  in  1902  some  slight  recurrence  of  pain. 
Well,  1903. 

Gall-scones  :  Cholecystotomy  and  Cholelithotrity. 

Case  313. — Eliza  L.,  aged  thirty-six,  admitted  to  the  infirmary 
March  21,  1900.  For  eighteen  months  the  patient  had  been 
subject  to  periodical  attack?  of  pain  in  the  right  hypochondrium 
with  vomiting  and  occasional  jaundice  ;  constipation  had  been  a 
marked  feature  of  her  illness.  These  attacks  had  come  at  weekly 
and  monthly  intervals,  and  the  monthly  attacks  were  usually 
connected  with  menstruation,  and  were  more  severe  than  the 
weekly  ones  ;  there  had  been  occasional  shivering.  The  pain  was 
situated  in  the  hepatic  area,  and  occasionally  felt  below  the  right 
shoulder-blade  ;  gall-stones  had  been  found  in  the  motions  ;  no 
enlargement  of  the  liver  or  gall-bladder. 

Operation. —  29/3/1900.  Gall-bladder  distended,  inflamed,  and 
surrounded  by  adhesions ;  cholecystotomy  ;  several  stones  with 
some  thick  dark  bile  removed ;  some  stones  worked  back  to  the 
gall-bladder  from  the  common  duct ;  one  large  stone  crushed  and 
scooped  out  piece-meal. 

After-History. — Patient  made  a  good  recovery. 

Gall-stones,  Jaundice,  Infective  Cholangitis  :  Choledochotomy. 

Case  314. — Mary  B.,  aged  forty-four,  seen  at  the  Leeds 
General  Infirmary.  She  gave  a  history  of  gall-stone  attacks  of 
fourteen  years'  duration  and  of  great  failure  in  health  ;  jaundice 
was  present,  and  was  intensified  after  each  seizure,  which  was 
accompanied  by  a  rigor. 

Operation. — 29/3/1900.  Choledochotomy  for  removal  of  gall- 
stones from  the  common  duct,  and  cholecystotomy  for  drainage. 

After-History. — Good  recovery  ;  the  patient  was  well  in  1901. 

Cancer  of  Liver  :  Exploratory  Operation. 

Case  315. — Mr.  W.,  aged  forty-five,  seen  with  Dr.  Reid,  Brad- 
ford. For  some  time  patient  had  been  subject  to  attacks  of 
indigestion  and  abdominal  pain,  but  had  never  been  jaundiced  ; 
for  the  last  four  months  had  been  losing  flesh  rapidly,  and  a 
tumour  was  detected  in  the  abdomen. 


400    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation. — 1 8/4/1 900.  Exploratory  laparotomy;  malignant 
disease  of  the  liver. 

After-History. — Patient  recovered  from  the  operation  and  lived 
for  three  months. 

Cancer  of  the  Pancreas  :  Cholecystotomy. 

Case  316.— Mrs.  T.,  aged  fifty,  seen  with  Dr.  Berry,  Keighley. 
Deep  jaundice  occurring  gradually  and  painlessly ;  rapid  loss  of 
flesh  and  strength  ;  enlarged  liver  ;  dilated  gall-bladder. 

Operation. — 23/4/1900.  Cholecystotomy  ;  cancer  of  the  head  of 
the  pancreas  discovered. 

After-History. — The  patient  bore  the  operation  well,  and  for  four 
days  was  quite  satisfactory,  when  smart  haemorrhage  into  the  gall- 
bladder occurred,  and  there  was  a  tendency  to  oozing  from  stitch 
punctures  ;  on  the  seventh  day  sudden  cerebral  haemorrhage  super- 
vened, rapidly  ending  in  coma. 

Gall-stones,  Pyloric  Adhesions,  Cholecystotomy :  Gastrolysis. 

Case  317. — Mrs.  R.,  aged  fifty,  seen  with  Dr.  Althorp,  Brad- 
ford. Twenty  years'  history  of  biliary  colic,  at  times  followed  by 
yellowness  of  the  conjunctivae,  but  never  actual  jaundice  ;  for  the 
last  two  years  the  attacks  had  been  more  frequent,  and  the  patient 
had  lost  2  stones  in  weight ;  some  distension  of  the  gall-bladder 
and  dilatation  of  the  stomach  present. 

Operation. — 25/4/1900.  Cholecystotomy;  nine  stones  removed 
from  the  gall-bladder  ;  firm  adhesions  to  the  pylorus  separated. 

After-History. — Good  recovery,  and  the  patient  gained  flesh 
and  remained  well  for  two  years  afterwards,  when  there  was  a 
recurrence  of  the  symptoms.     (See  Case  425.) 

Gall-stones  in  the  Common  Duct  removed  by  Scoop  after  Cholecystotomy. 

Chronic  Pancreatitis. 

Case  318. — Henry  L.,  aged  forty-four,  seen  at  the  infirmary. 
Six  months  previously  the  patient  had  an  attack  of  pain  in  the 
epigastrium  ;  he  had  had  several  attacks  since,  and  three  weeks 
before  admission  a  seizure  which  was  followed  by  jaundice.  Just 
above  the  umbilicus  a  tender  median  tumour  could  be  felt  ;  no 
enlargement  of  the  gall-bladder  or  liver  ;  slight  jaundice. 

Operation. — 21/5/1900.  Cholecystotomy;  185  small  stones  re- 
moved from  the  cystic  and  common  ducts  by  the  scoop ;  some 
enlargement  of  the  head  of  the  pancreas  (chronic  pancreatitis) ; 
gall-bladder  drained. 

After-History. — Patient  made  a  good  recovery. 


APPENDIX  401 

Gall-stone  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  :  Chole- 

cystotomy,  Choledochotomy. 

Case  319. — Mr.  S.,  aged  fifty-two,  seen  with  Dr.  Ellis,  Shipley. 
History  of  spasms  lasting  for  some  years,  and  in  later  years  there 
had  been  jaundice  and  infective  cholangitis  ;  a  gall-stone  floating 
in  the  common  duct. 

Operation. — 7/6/1900.     Choledochotomy  and  cholecystotomy. 

After-History. — Good  recovery;  the  patient  was  well  in  July, 
1901. 

Catarrhal  Cholecystitis,  Adhesions  :  Cholecystotomy. 

Case  320. — George  H.,  aged  forty-nine,  admitted  to  the  infir- 
mary, May  31,  1900.  Four  years  ago  was  said  to  have  had 
influenza,  which  was  followed  by  abdominal  pain  ;  since  then  he 
had  had  frequent  attacks  of  severe  pain  in  the  right  side  radiating 
round  to  the  back  and  up  into  the  neck.  Had  never  been  jaun- 
diced ;  there  had  been  some  loss  of  flesh  ;  some  tenderness  in  the 
right  hypochondrium  ;  no  enlargement  of  the  liver  or  gall-bladder. 

Operation. — 7/6/1900.  Gall-bladder  thickened  and  adherent, 
containing  mucus,  but  no  stones.  Adhesions  separated  and  gall- 
bladder drained. 

After-History. — The  patient  made  a  good  recovery  and  remained 
well. 

Gall-stones,  Cholecystitis,  Abscess  :  Cholecystotomy ;  Drainage; 

Gastrolysis. 

Case  321. — Mrs.  L.,  aged  thirty,  seen  with  Dr.  Hopkins, 
Leeds.  Two  years  ago  the  patient  had  had  symptoms  of  gastric 
ulcer,  and  on  one  occasion  had  had  violent  haematemesis  ;  three 
months  ago  had  a  violent  attack  of  pain  followed  by  jaundice  and 
distension  of  the  gall-bladder  ;  second  attack  six  weeks  ago,  since 
which  time  there  had  been  considerable  fever,  and  the  patient  had 
lost  flesh,  and  was  very  ill.     Stomach  dilated. 

Operation. — 8/6/1900.  Cholecystotomy  ;  an  abscess  was  found 
between  the  gall-bladder,  stomach,  and  liver,  containing  gall- 
stones ;  twelve  stones  were  found  in  the  gall-bladder,  cystic,  and 
common  ducts  ;  these  were  removed  through  an  incision  in  the 
gall-bladder.     Pyloric  adhesions  separated. 

After-History. — Good  though  slow  recovery.  Remained  well 
for  a  year,  when  had  recurrence  of  pain.     (See  Case  395.) 

Catarrhal  Cholecystitis,  Adhesions  :  Gastrolysis. 

Case  322. — Charlotte    H.,   aged    forty  -  nine,  admitted    to   the 

General  Infirmary,  June  4,  1900.     At  fourteen  years  of  age  the 

patient  had  an  attack  of  jaundice ;   for  the  last   few  years   had 

suffered  from  attacks  of  biliary  colic,  accompanied  by  vomiting 

26 


402    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

and  jaundice  ;  the  last  four  or  five  attacks  had  been  very  severe. 
No  enlargement  of  the  liver  or  gall- bladder  ;  some  tenderness  on 
deep  pressure  ;  stomach  dilated. 

Operation. — 1 2/6/1900.  Gall-bladder  shrunken  and  adherent; 
no  stones  palpable  in  gall-bladder  or  ducts;  adhesions  broken 
down  ;  abdomen  closed. 

After-History. — The  patient  made  a  good  recovery. 

Gall-stones,  Jaundice,  Suppurative  Cholangitis,  Empyema  of  Gall- 
bladder :  Cholecystotomy. 

Case  323. — John  R.,  aged  forty-seven,  admitted  to  the  General 
Infirmary,  June  9,  1900.  For  twenty  years  had  suffered  from 
attacks  of  biliary  colic ;  five  weeks  ago  had  a  very  severe  attack, 
followed  by  jaundice,  which  had  persisted  up  to  the  present  time ; 
vomiting  had  been  persistent  during  the  last  week ;  patient  had 
lost  considerable  flesh,  and  was  deeply  jaundiced ;  to  the  right  of 
the  epigastrium  a  hard,  rounded  mass  could  be  felt  below  the 
liver,  the  edge  of  which  could  be  felt  over  it  during  inspiration. 
While  in  the  hospital  the  jaundice  became  deeper,  and  his  tempera- 
ture was  above  ioo°  F.  every  evening. 

Operation. — 21/6/1900.  Incision  over  the  swelling;  after  dividing 
the  muscles,  a  mass  of  inflammatory  disease  was  cut  into,  and 
some  pus  met  with.  On  deepening  the  incision,  the  gall-bladder  was 
found  to  be  full  of  pus  and  gall-stones  ;  these  were  removed.  The 
incision  was  prolonged  downward ;  the  peritoneum  was  opened, 
and  the  ducts  explored  with  the  fingers.  Stones  were  felt  in 
the  common  duct ;  these  were  pushed  up  through  the  dilated 
cystic  duct  into  the  gall-bladder  and  extracted.  The  wall  of  the 
gall-bladder  could  not  be  clearly  defined,  as  there  was  a  consider- 
able hard,  nodular  mass  which  felt  like  malignant  growth.  A  large 
tube  was  inserted  into  the  gall-bladder  ;  the  rest  of  the  wound  was 
closed  in  the  ordinary  way. 

After -History. — The  patient  recovered  fairly  well  from  the 
operation,  but  did  not  make  much  headway;  the  jaundice  became 
more  intense,  and  the  patient  went  home  at  his  own  request  on 
July  1 1,  1900. 

Gall-stones  :  Cholecystotomy ;  Cholelithotrity ;  Gastrolysis. 

Case  324.— Edith  M.,  aged  forty-four,  admitted  to  the  General 
Infirmary,  June  12,  1900.  Ten  years  ago  the  patient  commenced 
to  have  pain  in  the  right  side  of  the  epigastrium,  which  was 
aggravated  by  taking  food  ;  this  trouble  subsided  at  the  end  of 
six  months  ;  lately  she  had  had  occasional  severe  attacks  of  pain 
after  food,  commencing  beneath  the  right  costal  margin,  radiating 
to  the  back  ;  there  had  been  no  jaundice  ;  patient  had  only  vomited 


APPENDIX  403 

On  one  occasion.  Bimanual  examination  revealed  slight  dilatation 
of  the  stomach. 

Operation. — 28/6/1900.  An  incision  was  made  over  the  gall- 
bladder, which  was  found  to  contain  gall-stones ;  cholecystotomy  ; 
five  large  stones  removed  from  the  gall-bladder  ;  one  impacted  in 
the  cystic  duct  was  crushed,  and  the  fragments  extracted  with  a 
scoop  ;  gall-bladder  drained  ;  gastrolysis  for  separation  of  pyloric 
adhesions. 

Aftev-Histovy. — Patient  made  a  good  recovery. 

Catarrhal  Cholecystitis,  Adhesions  :  Cholecystotomy;  Gastrolysis. 

Case  325.— Mrs.  S.,  aged  forty-two,  seen  with  Dr.  Schollick, 
Guildford.  Twenty  years'  history  of  attacks  of  biliary  colic  ;  no 
jaundice  or  rigors  ;  stomach  symptoms  with  '  spasms.' 

Operation. — 11/7/1900.  Cholecystotomy;  no  gall-stones  found  ; 
adhesions  of  the  gall-bladder  and  cystic  duct  to  the  duodenum, 
pylorus  and  omentum  producing  kinking  of  the  cystic  duct ; 
adhesions  separated. 

After-History. — Good  recovery. 

Biliary  Fistula  closed  by  Plastic  Operation. 

Case  326. — Kate  F.,  aged  thirty-one,  seen  at  the  Leeds  General 
Infirmary.  Eight  months  previously  the  patient  was  operated 
on  by  another  surgeon  for  gall-stones ;  a  biliary  fistula  persisted. 

Operation. —  1 9/7/1900.  Plastic  operation  and  closure  of  the 
fistula  ;  ducts  explored  ;  no  cause  for  obstruction  found  ;  opening 
in  the  gall-bladder  closed  by  sutures. 

After -History. — Patient  made  a  good  recovery,  and  remains  well. 

Cancer  of  the  Pancreas  :  Cholecystotomy . 

Case  327. — Mrs.  H.,  aged  sixty-five,  seen  with  Dr.  Home, 
Scarborough.  Two  years  ago  patient  had  some  enlarged  glands 
removed  from  the  groin,  which  were  thought  to  be  sarcomatous  ; 
six  weeks  ago  jaundice  came  on  suddenly,  accompanied  by  pain  ; 
some  enlargement  of  the  liver  and  distension  of  the  gall-bladder, 
with  a  tumour  of  the  pancreas. 

Operation. — 22/7/1900.  Cholecystotomy;  malignant  disease  of 
the  head  of  the  pancreas. 

After-History. — Patient  made  a  good  recovery  from  the  opera- 
tion, and  lived  for  some  months. 

Acute  Cholecystitis  during  Course  of  Typhoid  Fever,  Repeated  Rigors, 
Delirium,  High  Temperature. 

Case  328. — Mr.  G.,  aged  fifty,  seen  with  Dr.  Herbert  J.  Robson, 
Leeds.     Swelling  of  the  gall-bladder  ;  enlarged  cirrhotic  liver  and 

26—2 


404    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

some  ascites  ;  high  fever  and  delirium  had  been  present  for  three 
weeks. 

Operation. — 24/7/1900.  Gall-bladder  acutely  inflamed  and  con- 
taining pus  ;  drainage. 

After-History. — Patient  in  delirium  dragged  the  tube  out  at  the 
end  of  twenty-four  hours ;  five  days  later  it  was  re-inserted,  as 
drainage  was  defective.  The  patient  continued  delirious  and 
unaltered  in  his  general  condition  for  about  a  fortnight,  when 
he  succumbed  to  typhoid  symptoms,  but  without  any  sign  of 
peritonitis. 

Gail-stones  in  Common  Duct:  Duodeno-choledochotomy ;  Cholecystotomy. 

Case  329. — Miss  W.,  aged  twenty-eight,  seen  with  Dr.  Graham, 
Cockermouth.  For  some  time  the  patient  had  suffered  from 
indigestion,  and  for  the  last  six  months  had  had  more  or  less  con- 
tinuous pain  over  the  gall-bladder ;  three  months  ago  had  a  violent 
attack  of  biliary  colic,  followed  by  jaundice,  which  partly  dis- 
appeared in  a  few  days ;  since  then  the  attacks  had  been  frequent, 
and  always  followed  by  jaundice  ;  loss  of  flesh. 

Operation. — 24/7/1900.  Duodeno-choledochotomy  and  chole- 
cystotomy ;  catarrh  of  the  gall-bladder ;  two  stones  impacted  at 
the  ampulla  of  Vater. 

After-History. — Good  recovery.     Well,  October,  1903. 

Cancer  of  Gall-bladder,  Liver,   and  Pylorus,   Gall-stones :  Cholecystec- 
tomy ;  Hepatectomy  and  Pylorectomy. 

Case  330. — Mrs.  S.,  aged  sixty-three,  seen  with  Dr.  Fry,  Oak- 
worth.     (See  p.  190.)     Patient  well,  1903. 

Gall-stones,  Jaundice,  and  Infective  Cholangitis  :  Choledochotomy ; 

Cholecystotomy. 

Case  331. — Mrs.  S.,  aged  fifty-four.  Two  years  previously  the 
patient  had  an  attack  of  biliary  colic,  followed  by  jaundice ;  there 
had  been  several  severe  attacks  since,  with  ague-like  seizures  and 
loss  of  weight. 

Operation. — 22/8/1900.  Choledochotomy  and  cholecystotomy; 
five  stones  removed  from  the  common  duct. 

After -History. — Good  recovery  ;  the  patient  was  well  in  June, 
1903. 

Gall-stone  in  Common  Duct,  Jaundice,  Infective  Cholangitis  :  Chole- 
dochotomy ;  Cholecystotomy. 

Case  332.  — Mr.  H.,  aged  fifty-six,  seen  with  Dr.  Barrs,  Leeds. 
For  twenty-five  years  patient  had  been  troubled  with  diarrhoea 
and  indigestion  ;  the  first  attack  of  gall-stone  colic  and  jaundice 
occurred  six  months  previously. 


APPENDIX  405 

Operation. — 22/8/1900.  Choledochotomy  and  cholecystotomy ; 
one  stone  was  ulcerating  through  the  gall-bladder,  and  one  was 
in  the  common  duct ;  there  was  muco-pus  in  the  ducts  ;  suppura- 
tive cholangitis  was  present  ;  posterior  drainage  was  employed. 
Recovery  was  tardy  but  satisfactory. 

After- History. — The  patient  has  been  well  since,  except  for  occa- 
sional attacks  of  pain,  probably  due  to  catarrh. 

Jaundice,  Biliary  Fistula  :  Exploratory  Operation. 

Case  333  — Miss  B.,  seen  in  Shropshire.  Operation  by  a 
surgeon  in  London,  Christmas,  1899,  when  gall-stones  were 
removed.  Some  relief  was  given  for  a  time,  but  the  jaundice 
never  cleared  up,  and  had  recently  become  more  intense ; 
moreover,  there  was  a  biliary  fistula,  with  very  imperfect 
drainage. 

Operation. — 1/9/1900.  Adhesions  almost  insuperable,  and  with 
great  difficulty  the  ducts  were  exposed ;  no  gall-stones  felt ;  gall- 
bladder and  ducts  shrunken,  probably  strictured  ;  hepatic  duct  on 
surface  of  liver  opened  on  separating  adhesions  :  this  laceration 
poured  out  bile  very  freely,  much  more  so  than  the  biliary  fistula ; 
abdomen  closed  around  a  drain. 

After-History. — Unfortunately,  on  account  of  pain,  morphia  was 
administered  on  the  evening  of  operation  and  subsequently  (con- 
trary to  my  usual  custom) ;  this  was  followed  by  distension  of 
the  abdomen  and  difficulty  in  breathing  ;  bile  flowed  freely  from 
the  liver,  but  very  little  from  the  tube  ;  death  occurred  on  the  third 
day. 

Cancer  of  Gall-bladder  and  Colon  :  Cholecystectomy,  Colectomy,  and 

Hepatectomy. 

Case  334. — Jane  A.,  aged  forty-three  (see  Case  309).  After  the 
previous  operation,  in  February,  a  good  many  concretions  came 
away  through  the  fistula.  On  re-admission,  there  was  a  free  dis- 
charge of  muco-pus,  and  a  hard  mass  could  be  felt  below  the 
fistula. 

Operation. — 13/9/ 1900.  Gall-bladder  was  much  enlarged  and 
infiltrated  with  hard  growth,  which  was  invading  the  liver  close 
to  the  gall-bladder,  as  well  as  the  hepatic  flexure  of  the  colon ; 
about  6  inches  of  colon  were  removed,  and  the  extremities  were 
united  by  a  Murphy's  button  ;  the  cystic  duct  and  the  border  of 
the  liver  were  transfixed  with  a  pin,  and  a  rubber  ligature  applied 
below  the  pin,  which  was  brought  out  of  the  wound,  the  gall- 
bladder and  affected  portion  of  liver  being  then  amputated. 

After-History. — The  patient  rallied  well  from  the  operation,  and, 
as  the  whole  of  the  disease  had  apparently  been  removed,  good 


406    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

hopes  of  recovery  were  entertained,  but  on   the  second  day  the 
heart  began  to  fail,  and  death  occurred  from  exhaustion. 

Gall-stones  :  Choi e cystotomy. 

Case  335. — Martha  Crowther,  aged  forty-five,  admitted  to  the 
General  Infirmary,  September  10,  1900.  Five  years'  history  of 
biliary  colic,  but  no  jaundice ;  recently  the  attacks  had  become 
more  frequent  and  more  severe ;  gall-stones  had  been  found  in 
the  motions ;  no  enlargement  of  the  liver  or  gall-bladder  ;  some 
tenderness  on  deep  pressure. 

Operation. —  1 4/9/1 900.  Cholecystotomy  ;  forty  faceted  gall- 
stones removed  ;  tube  secured  into  gall-bladder  by  a  purse-string 
suture. 

After-History. — Patient  made  a  good  recovery. 

Gall-stones :  Cholecystotomy. 

Case  336. — Mrs.  S.,  aged  fifty-four,  seen  with  Dr.  Hawthorn, 
Sheffield.  For  fifteen  years  the  patient  had  suffered  from  attacks 
of  biliary  colic,  which  were  always  followed  by  jaundice ;  there 
had  been  some  loss  of  flesh,  but  no  rigors ;  some  enlargement  of 
the  right  lobe  of  the  liver  ;  no  distension  of  the  gall-bladder  ; 
marked  tenderness  above  the  umbilicus. 

Operation. — 23/9/1900.  Cholecystotomy;  one  gall-stone  re- 
moved from  the  gall-bladder,  one  impacted  in  the  cystic  duct  was 
crushed  and  removed  with  the  scoop  ;  adhesions  between  the  gall- 
bladder and  duodenum  separated. 

After-History. — Good  recovery  ;  well,  July,  1903. 

Gall-stones,  Empyema  of  Gall-bladder :  Cholecystotomy. 

Case  337. — John  T.  B.,  aged  thirty-six,  admitted  to  the  General 
Infirmary,  September  21,  1900.  Eighteen  months'  history  of 
severe  biliary  colic,  always  followed  by  jaundice,  which  cleared 
up  in  two  or  three  days.  Patient  was  in  good  condition,  and  there 
was  no  jaundice  ;  no  tenderness. 

Operation. — 27/9/1900.  Gall-bladder  found  to  be  small  and  re- 
tracted far  up  under  the  liver.  It  could  not  be  brought  near  to  the 
surface.  Gall-bladder  was  incised,  and  two  large  and  several 
small  stones,  together  with  some  pus,  removed  from  it.  Owing  to 
the  impossibility  of  bringing  the  gall-bladder  to  the  surface,  and 
the  difficulty  of  fastening  in  a  tube,  the  opening  in  the  gall-bladder 
was  sutured,  some  gauze  packing  arranged  around  it,  and  a 
drainage-tube  passed  into  the  right  kidney-pouch. 

After -History. — The  patient  made  a  good  recovery. 


A  PPENDIX  407 

Gall-stones  :  Cholecystotomy. 

Case  338.  — Mrs.  F.,  aged  thirty-five,  seen  with  Dr.  Mackenzie, 
Douglas.  For  five  years  the  patient  had  been  subject  to  attacks 
of  biliary  colic ;  for  a  month  had  had  continuous  pain,  with 
enlargement  of  the  gall-bladder. 

Operation. — 4/ 10/ 1900.  Cholecystotomy  ;  two  stones  removed 
from  the  gall-bladder,  and  one  from  the  cystic  duct. 

After-History. — Good  recovery.     Wound  healed  by  first  inten- 
tion, but  some  time  afterwards  a  slight  mucous  fistula  developed. 
Gall-stones  :  Cholecystotomy. 

Case  339.  —  Samuel  M.,  aged  forty-two,  admitted  to  the 
infirmary,  September  27,  1900.  For  two  years  a  history  of  severe 
attacks  of  abdominal  pain,  always  followed  by  jaundice ;  gall- 
stones had  been  found  in  the  motions  on  several  occasions ;  no 
enlargement  of  the  liver  or  gall-bladder;  some  tenderness  present. 

Operation. — 4/ 10/ 1900.  Gall-bladder  involved  in  adhesions, 
shrunken,  and  retracted  beneath  the  edge  of  the  liver  ;  chole- 
cystotomy ;  two  small  stones  extracted  piecemeal  with  a  scoop ; 
as  the  gall-bladder  could  not  be  brought  up  to  the  surface,  it  was 
closed  by  a  double  layer  of  catgut  sutures  and  a  drain  passed 
down  to  the  sutured  incision. 

After -History. — The  patient  made  a  good  recovery. 

Cholelithiasis  :  Cholecystectomy ;  Partial  Hepatectomy. 

Case  340. — Emma  L.,  aged  forty-two,  seen  at  the  Leeds 
General  Infirmary.     (See  p.  170.) 

Cholecystitis  :  Cholecystotomy. 

Case  341. — Mrs.  W.,  aged  thirty-six,  seen  with  Dr.  Liddell, 
Harrogate.  Had  had  cholecystotomy  for  gall-stones,  November 
25,  1897,  and  had  been  well  for  over  two  years,  when  she  began 
to  have  attacks  of  abdominal  pain ;  during  the  last  few  weeks 
the  pain  had  been  constant  and  accompanied  by  slight  jaundice. 
The  gall-bladder  was  distended  and  tender,  and  the  right  kidney 
was  freely  movable. 

Operation. — 25/10/1900.  Gall-bladder  distended  with  muco-pus; 
duct  thickened  and  ulcerated ;  cholecystotomy ;  drainage  con- 
tinued for  some  considerable  time. 

After-History. — Ultimately  got  quite  well.     Well,  1902. 

Gall-stcnes  in  Common  Duct,  Jaundice,  Infective  Cholangitis  : 

Choledochotomy . 
Case  342. — Mrs.  D.,  aged  forty-three,  seen  with  Dr.  Davies, 
Newport.  She  had  suffered  from  biliary  colic  for  six  years,  and 
from  jaundice  for  two  months  ;  two  recent  colicky  attacks  had 
been  followed  by  fever  and  rigors ;  there  were  jaundice  and 
infective  cholangitis. 


408    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation. — 26/10/1900.  Choledochotomy  ;  one  rough  stone 
removed  from  the  common  duct ;  anterior  drainage  was  adopted. 
After  a  severe  attack  on  July  19, 1 901,  another  gall-stone  was  passed. 

After-History. — The  patient  was  well  in  November,  1901. 

Chronic  Pancreatitis  with  A  bscess  associated  with  Gall-stones :  Chole- 
cystotomy  ;  Relief;  Death  Four  Months  later  from  Exhaustion  ; 
Necropsy. 

Case  343.— Mr.  H.,  aged  forty,  was  seen  by  me  with  Dr.  Woods, 
of  Batley,  on  October  11,  1900. 

Condition  when  First  Seen. — The  patient  was  then  deeply  jaundiced 
and  extremely  ill,  suffering  from  continuous  fever,  with  exacerba- 
tions, great  debility,  and  extreme  emaciation.  A  large  tumour  in 
the  region  of  the  pancreas  could  then  be  felt,  as  well  as  a  distended 
gall-bladder. 

History. — He  had  been  failing  in  health  for  nine  months,  and 
gave  a  history  of  gall-stone  attacks  and  painful  indigestion  for 
some  time  before  that,  but,  although  he  had  had  frequent  attacks 
of  abdominal  pain  for  three  or  four  months,  the  jaundice  had  only 
supervened  a  fortnight  before  my  seeing  him. 

Operation. — He  was  too  ill  to  bear  a  prolonged  search,  and  there 
were  numerous  adhesions  around  the  tumour,  which  wras  made 
out  to  be  a  swelling  of  the  pancreas ;  the  gall-bladder  was  simply 
opened  and  drained  of  a  quantity  of  muco-pus.  A  quantity  of 
pus  was  discharged  from  the  drainage-tube  several  days  after 
operation,  and  this  was  repeated  on  two  or  three  occasions,  as  if 
it  came  from  a  deeply-seated  abscess.  A  large  drainage-tube 
having  been  used,  there  was  a  free  discharge  of  bile,  and  a  con- 
siderable number  of  gall-stones  were  evacuated  through  it — 
thirty-three  in  all. 

After -History. — Previous  to  the  operation  the  patient  was 
suffering  from  shivering  attacks  and  a  persistently  elevated  tem- 
perature, which  subsided  immediately  after  drainage  was  effected, 
and  the  temperature  kept  nearly  normal  throughout  the  remainder 
of  his  illness,  it  being  normal  in  the  morning,  though  there  was 
usually  a  hectic  rise  each  evening.  He  made  slow  though 
apparently  steady  recovery  from  the  operation,  and  the  pancreatic 
tumour  diminished  so  rapidly  that  it  was  confidently  believed  to 
be  entirely  disappearing,  it  being  only  one-third  as  large  as  at  the 
time  of  operation.  He  returned  home  on  December  14,  but  he 
never  really  picked  up  strength,  and,  though  there  was  no  further 
elevation  of  temperature,  he  gradually  got  weaker,  and  died  in 
February. 

Necropsy. — At  the  post-mortem  examination  made  by  Dr.  Woods, 
a  tumour  of  the   pancreas   was   discovered  which  was  carefully 


A  PPENDIX  409 

examined  by  Mr.  Cammidge  and  pronounced  to  be  a  chronic 
inflammatory  tumour,  and  not  new  growth,  the  centre  being 
occupied  by  pulpy  material  where  the  abscess  had  originally  been. 
Nothing  else  was  discovered,  and  there  were  no  gall-stones  left 
either  in  the  gall-bladder  or  ducts. 

Gall-stones,  Tumour  of  Liver  :  Cholecystotomy  ;  Hepatectomy. 

Case  344.  —  William  W.,  aged  forty-one,  admitted  to  the 
General  Infirmary,  November  19,  1900.  Eighteen  months  ago 
had  the  first  attack  of  biliary  colic,  which  was  accompanied  by 
vomiting  and  followed  by  jaundice,  which  had  persisted  for  five 
or  six  weeks,  during  which  time  he  had  had  recurring  attacks  of 
pain  and  vomiting;  had  had  similar  attacks  since  ;  three  months 
ago  had  a  very  severe  attack  of  pain  followed  by  jaundice,  which 
persisted  for  two  months ;  had  lost  3  stones  in  weight.  On 
admission  there  wras  no  jaundice. 

Operation. — 29/11/1900.  Gall-bladder  enlarged  and  distended; 
three  gall-stones  removed  ;  gall-bladder  drained.  A  small  pedun- 
culated growth  removed  from  the  margin  of  the  liver. 

After-History. — Patient  made  a  good  recovery. 

Cancer  of  the  Cystic  Duct,  with  Gall-stones :  Cholecystotomy. 

Case  345. — John  B.,  aged  fifty-seven,  seen  at  the  Leeds  General 
Infirmary.  Patient  had  been  well  up  to  twelve  months  before 
admission,  when  he  began  to  suffer  from  painful  dyspepsia. 
Three  months  previous  to  admission  the  pain  became  more 
severe,  but  there  was  no  jaundice  ;  there  had  been  frequent 
vomiting,  and  the  patient  had  lost  weight  and  strength,  and  looked 
cachectic ;  a  slight  icteric  tinge  in  the  conjunctivae  could  be  seen, 
and  a  hard  mass  could  be  felt  in  the  right  hypochondrium. 

Operation. — 29/11/1900.  Cholecystotomy;  500  small  stones 
removed  from  the  gall-bladder,  and  one  about  the  size  of  a  pigeon's 
egg,  through  an  incision  in  the  cystic  duct ;  the  cystic  duct  was 
infiltrated  with  new  growth. 

After-History. — The  patient  died  on  the  second  day  from  shock. 

Ulceration  and  Perforation  of  Bile-ducts,  Peritonitis  :  Drainage. 

Case  346. — Mrs.  T.,  aged  sixty,  seen  with  Dr.  Crawford 
Watson,  Harrogate,  suffering  from  peritonitis,  with  distension 
of  the  abdomen  and  partial  obstruction  of  the  bowel ;  clear 
history  of  gall-stones  for  several  years,  and  of  sudden  pain  on  the 
right  of  the  abdomen  a  week  previous  to  my  seeing  her.  There 
was  an  old  umbilical  hernia.  A  fluid  wave  felt  on  the  right  side  of 
the  abdomen  before  operation. 

Operation. — 6/12/19C0.     Laparotomy;  large  collection  of  pus  and 


4io    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

bile  discovered  on  the  right  of  the  abdomen,  due  to  perforation  of 
the  bile-ducts,  the  exact  site  of  which  could  not  be  made  out  on 
account  of  the  extensive  adhesions ;  bowels  tied  down  by  adhe- 
sions extending  from  the  umbilical  hernia ;  general  paralytic  dis- 
tension of  intestine  due  to  peritonitis  ;  separation  of  adhesions ; 
drainage  of  the  infected  area ;  free  purging  by  calomel. 

After '-History. — Patient  much  relieved  at  first,  and  for  three  days 
promised  to  do  well ;  pneumonia  developed  on  the  fourth  day  and 
proved  fatal  on  the  sixth. 

Gall-stones :  Cholecystotomy. 

Case  347. — Annie  J.,  aged  thirty-two,  admitted  to  the  General 
Infirmary,  November  22,  igoo.  For  six  years  had  had  occasional 
abdominal  pain  ;  recently  the  attacks  had  occurred  every  day  ; 
the  pain  had  been  very  severe,  starting  in  the  right  hypochon- 
drium,  and  running  to  the  back  and  the  right  shoulder  ;  jaundice 
occurred  about  a  week  before,  and  lasted  four  or  five  days  ;  a 
thickened  mass  was  felt  in  the  epigastrium,  the  right  hypochon- 
drium,  and  in  the  region  of  the  gall-bladder,  which  was  tender  on 
pressure. 

Operation. — 6/12/1900.  Cholecystotomy;  forty  stones  removed 
from  the  gall-bladder. 

After-History  .—The  patient  made  a  good  recovery. 

Gall-stones,  Dilated  Stomach  :  Cholecystotomy  ;  Gastrolysis. 

Case  348. — Annie  W.,  aged  thirty-eight,  admitted  to  the 
General  Infirmary,  December  19,  1900.  For  two  years  had  had 
attacks  of  pain  in  the  right  side  of  the  abdomen  which  had 
become  more  frequent  during  the  last  two  months ;  lately  the 
attacks  had  been  followed  by  jaundice.  The  patient  complained 
very  much  of  flatulence  and  distension  of  the  abdomen  after  food  ; 
stomach  considerably  dilated,  extending  1^  inches  below  the  um- 
bilicus ;  no  tumour  to  be  detected. 

Operation. — 3/1/1901.  Cholecystotomy  :  twelve  stones  removed 
from  the  gall-bladder;  extensive  adhesions  between  the  gall- 
bladder, omentum,  pylorus,  and  colon  ;  stomach  much  dilated  ; 
gastrolysis. 

After -History. — Good  recovery. 

G all -sto ucs  :  Cholecystotomy. 

Case  349. — Mr.  T.,  aged  fifty-one,  seen  with  Dr.  Knight, 
Rotherham.  Fifteen  years  ago  had  several  attacks  of  biliary  colic 
with  considerable  loss  of  flesh  ;  was  free  from  attacks  for  some 
years  ;  some  months  ago  the  attacks  recurred  and  were  followed 
by  jaundice,  and  several  stones  were  passed. 


APPENDIX  41 1 

Operation. — 4/1/1901.  Cholecystectomy;  gall-bladder  contracted 
and  contained  several  gall-stones ;  one  large  stone  removed  from 
the  cystic  duct. 

After-History. — Patient  made  a  good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  350. — Mary  Jane  F.,  aged  twenty-seven,  admitted  to  the 
General  Infirmary,  January  8,  1901.  For  six  months  frequent 
attacks  of  biliary  colic  with  vomiting  and  loss  of  flesh. 

Operation. — 1 7 /1/1901.  Cholecystotomy;  five  gall-stones  re- 
moved from  the  gall-bladder. 

After -History. — Good  recovery. 

Gall-stones,  Empyema  of  Gall-bladder  :   Cholecystotomy. 

Case  351. — Mr.  G.,  aged  forty-five,  seen  with  Dr.  Mercer, 
Bradford.  During  the  last  few  months  patient  had  had  several 
attacks  of  biliary  colic,  and  had  been  slightly  jaundiced  on  several 
occasions ;  had  lost  40  pounds  in  weight,  and  had  become  very 
anaemic  ;  gall-bladder  enlarged  and  tender. 

Operation. — 17/1/1901.  Cholecystotomy;  empyema  of  the  gall- 
bladder ;  one  stone  removed  from  the  cystic  duct ;  the  gall-bladder 
could  not  be  brought  to  the  surface. 

After-History. — Good  recovery. 

Gall-stones  in  Common  Duct :  Choledochotomy  and  Cholecystotomy. 

Case  352. — Elizabeth  H.,  aged  forty-five,  seen  at  the  General 
Infirmary.  Had  had  colic  for  eight  years  ;  jaundice  was  present, 
and  was  increased  after  each  attack. 

Operation. — 21/1/1901.  Choledochotomy  and  cholecystotomy; 
several  gall-stones  were  removed  from  the  gall-bladder  and  the 
common  duct,  and  a  good  recovery  followed. 

Gall-stones  :  Cholecystotomy. 

Case  353. — Lavinia  M.,  aged  thirty-six,  admitted  to  the 
General  Infirmary,  January  5,  1901.  Twelve  weeks  ago  had  had 
an  attack  of  pain  in  the  right  hypochondrium,  passing  through  to 
the  back,  followed  by  jaundice  in  a  few  hours  ;  since  then  the 
attacks  had  been  frequent  and  always  followed  by  persistent  jaun- 
dice ;  considerable  tenderness  over  gall-bladder ;  no  enlargement 
of  the  gall-bladder  or  liver. 

Operation. — 24/1/1901.  Cholecystotomy;  nine  stones  removed 
from  the  gall-bladder. 

After- History. — Good  recovery. 


412    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Large  Gall-stone  in  Common  Duct :  Chronic  Pancreatitis ;  Duodeno- 
choledochotomy  ;  Subsequent  Hemorrhage  controlled  by  Chloride  of 
Calcium. 

Case    354. — M.   E.  G.,  a  married   woman,    aged    thirty-eight 
years,  was  admitted  to  the  Leeds  General  Infirmary  on  January 
23,   1901.     She  had  had  typhoid  fever  in  September,   1899,  and 
had  never  been  quite  well  since.     Shortly  afterwards  she  began  to 
suffer   from  biliary  colic,  though  she  had  never  been  jaundiced 
till  six  months  before  admission,  from  which  time  jaundice  had 
never  left  her.     On  December  24,  1900,  she  became  much  worse, 
and  had  very  severe  paroxysmal  pain,  accompanied  by  shivering 
and  profuse  sweats.     From  that  time  she  lost  weight  very  rapidly, 
and  the  jaundice  deepened.     On  admission,  the  liver  could  be  felt 
below  the  ribs,  and  there  was  a  distinct  fulness  on  deep  palpation 
in  the  region  of  the  pancreas.     From  January  21  to  31  she  took 
calcium  chloride  in  20-grain  doses  thrice  daily.     Duodeno-chole- 
dochotomy  was  performed  on  January  31.     There  was  very  little 
bleeding.     A  stone  nearly  as  large  as  a  pigeon's  egg  was  removed 
from  the  ampulla  of  Vater,  which  was  laid  open  over  a  director 
introduced  through  the  papilla  at  its  opening  into  the  duodenum. 
The  head  of  the  pancreas  was  felt  to  be  much  enlarged  and  hard. 
The  incision  into  the  ampulla  was  not  sutured,  and  through  it  the 
common  bile-duct,  very  much  dilated,  was  explored  by  the  finger. 
The   anterior    wound    in  the  duodenum  was  then  sutured,    and 
the  abdominal  wound  was  closed.     A  drainage-tube  was  inserted 
through  a  stab  wound  in  the  right  loin.    The  patient  inadvertently 
did  not  have  calcium  chloride  given  in  the  nutrient  enemata,  as  is 
usual  in  these  cases.     She  did  well  till  the  morning  of  February  2, 
when  the  nurse  noticed  at  three  o'clock  that  the  dressings  were 
soaked  with  bright  blood.     The  drainage  wound  was  exposed,  but 
no  haemorrhage  was  occurring  there.    On  examining  the  abdominal 
incision,  blood  was  seen  to  be  slowly  oozing  from  it  and  from  the 
stitch  punctures.     One  drachm  of  calcium  chloride  was  adminis- 
tered at  once  by  the  mouth,  and  three  stitches  were  removed  ;  the 
surface  of  the  wound  was  then  seen  to  be  oozing  all  over.     It  was 
packed  with  gauze  soaked  in  tincture  of  hamamelis,  and  a  firm 
dressing  was  applied.     One  drachm  of  calcium  chloride  was  given 
again  in  two  hours,  and  afterwards  it  was  repeated  in  30-grain 
doses  every  two  hours  for  six  times,  the  drug  being  then  given 
thrice  daily.     There  was  no  recurrence  of  haemorrhage,  and  the 
patient  made  an  uninterrupted  recovery.     The  drainage-tube  was 
removed  on  the  4th,  and  she  returned  home  within  the  month. 
An  examination  of  the  blood  showed  a  very  marked  diminution  in 
the  blood-plates.     Well  when  heard  of  some  months  later. 


APPENDIX  413 

Catarrh  of  Gall-bladder  :  Cholecystotomy  ;  Gastrolysis. 

Case  355. — Mr.  M.,  seen  with  Dr.  Tilley,  London.  Four 
years  ago  the  patient  had  biliary  colic,  followed  by  jaundice  ;  since 
then  he  had  been  subject  to  attacks  of  pain  in  the  abdomen  ;  no 
vomiting,  but  loss  of  flesh  ;  the  gall-bladder  is  said  to  have  been 
enlarged  during  several  of  the  attacks,  and  was  very  tender  ;  some 
dilatation  of  the  stomach. 

Operation. —  31/1/1901.  Cholecystotomy;  gall-bladder  small  and 
contracted,  and  firmly  adherent  to  the  pylorus  ;  no  gall-stones 
present. 

After -History. — Good  recovery  from  operation,  but  had  further 
trouble  with  the  dilated  stomach,  which  was  treated  by  rest 
and  general  massage.     Well,  1903. 

Chronic  Pancreatitis  :  Cholecystotomy. 

Case  356. — Robert  H.,  aged  twenty-six,  seen  at  the  Leeds 
General  Infirmary.  Patient  was  deeply  jaundiced,  and  had  had 
jaundice  since  the  age  of  seventeen,  it  having  supervened  upon  a 
severe  attack  of  what  appeared  to  be  biliary  colic,  of  which  he  had 
had  several  seizures  since  the  age  of  fourteen.  For  two  or  three 
years  he  had  had  several  ague-like  attacks,  and  during  that  time 
he  lost  very  seriously  in  weight  and  strength ;  but  during  the  past 
two  years  there  had  been  no  shivers,  and  he  had  also  been  free  from 
the  severe  paroxysms  of  pain,  though  he  had  had  slighter  seizures, 
after  all  of  which  the  jaundice  became  more  intense.  The  patient 
was  then  only  weighing  9  stones,  and  all  the  bile  was  apparently 
passing  into  the  urine  and  none  by  the  bowels  ;  there  was  some 
swelling  in  the  region  of  the  pancreas,  slight  enlargement  of  the 
liver,  and  a  very  decided  enlargement  of  the  spleen.  Fine  pan- 
creatic crystals  found. 

Operation. — 31/1/1901.  Cholecystotomy;  the  gall-bladder  was 
contracted  and  adherent ;  the  head  of  the  pancreas  was  found  to 
be  enlarged  and  very  hard  ;  no  gall-stones.  The  gall-bladder  was 
drained.  For  a  few  days  the  jaundice  was  deeper  ;  it  then  became 
gradually  less  until  it  almost  disappeared.  In  ten  days  the  stools 
became  bile-stained,  and  have  since  retained  their  colour,  though 
there  has  never  been  complete  freedom  from  a  tinge  of  jaundice  in 
the  skin. 

After-History. — He  returned  home  on  April  16,  having  gained 
nearly  \  stone  in  weight.    For  subsequent  history,  see  Case  397. 

Gall-stones  in    Common  Duct,  Gall-bladder -Duodenal  Fistula  :   Chole  - 
dochotomy  and  Cholecystotomy  ;  Repair  of  Fistula  ;  Gastrolysis. 
Case  357.— Mrs.  C,  aged  fifty,   seen  with   Dr.    H.   Mitchell, 
Cockermouth.    She  had  suffered  from  attacks  of  colic  over  a  long 
period  of  time  ;  jaundice  was  moderate. 


4H    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation. — 6/2/1901.  Choledochotomy  and  cholecystotomy  ; 
two  stones  removed  from  the  gall-bladder  and  one  from  the 
common  duct ;  there  was  a  fistula  between  the  gall-bladder  and 
the  duodenum,  which  was  repaired.     Pyloric  adhesions  separated. 

After-History. — Complete  recovery  followed,  and  the  patient 
was  well  in  September,  1903. 

Cancer  of  Pancreas  :  Cholecystotomy. 

Case  358. — Mr.  S.,  aged  sixty-five,  seen  with  Dr.  Russell, 
Brigg.  Six  months  before,  the  patient  had  a  severe  attack  of 
abdominal  pain,  followed  by  slight  jaundice;  two  weeks  ago  had 
another  attack  of  pain,  followed  by  jaundice,  which  persisted ; 
there  had  been  considerable  loss  of  flesh  ;  slight  enlargement 
of  the  liver,  but  no  definite  enlargement  of  either  the  gall- 
bladder or  pancreas  could  be  felt,  and  there  was  no  marked 
tenderness. 

Operation. — 14/2/1901.  Cholecystotomy;  malignant  disease  of 
the  head  of  the  pancreas  ;  no  gall-stones  found. 

After-History. — Patient  died  from  post-operative  haematemesis 
thirty  hours  after  operation. 

Gall-stones  :  Cholecystotomy. 

Case  359. — Sarah  N.,  aged  fifty-nine,  admitted  to  the  General 
Infirmary,  February  11,  1901.  For  six  weeks  had  had  very 
severe  attacks  of  pain  in  the  right  hypochondriac  region,  followed 
by  jaundice  and  loss  of  flesh  ;  no  enlargement  of  the  gall-bladder, 
but  considerable  tenderness. 

Operation. — 15/2/1901.  Cholecystotomy;  thirty  stones  removed 
from  the  gall-bladder. 

After-History. — Good  recovery. 

Infective  Cholangitis,  Gall-bladder-Duodenal  Fistula,  Jaundice :  Chole- 
dochotomy ;  Cholecystotomy  ;  Ether  Bronchitis. 

Case  360. — John  O'C,  aged  fifty-two  years,  who  was  seen 
at  the  General  Infirmary,  had  had  symptoms  for  twenty  years — 
'  pains,  etc'  There  were  infective  cholangitis,  with  great  loss  of 
flesh  and  strength,  and  a  fistula  between  the  gall-bladder  and 
duodenum  ;  intense  adhesions  and  jaundice. 

Operation. — Choledochotomy,  with  closure  of  the  fistula,  and 
cholecystotomy,  were  carried  out  on  February  15,  1901. 

After- J I i story. — The  patient  took  ether  badly,  became  livid,  and 
had  much  mucus  in  the  bronchi.  He  was  never  able  to  clear  the 
lungs,  and  died  from  acute  congestive  bronchitis  six  hours 
later. 


APPENDIX  415 

Gall-stones,  Dilatation  of  Stomach  :  Cholecystotomy  ;  Gastrolysis. 

Case  361. — Mr.  F.,  aged  thirty-four,  seen  with  Dr.  Hebble- 
thwaite,  Keighley.  Thirteen  years  ago  patient  had  typhoid  fever, 
and  soon  afterwards  began  to  suffer  from  pain  in  the  right 
hypochondrium.  He  had  never  been  jaundiced,  but  had  suffered 
from  repeated  painful  attacks,  which  had  become  more  severe 
lately,  and  were  associated  with  loss  of  flesh  ;  no  enlargement  of 
the  gall-bladder,  but  tenderness  below  the  costal  margin  ;  some 
dilatation  of  the  stomach. 

Operation. — 12/3/1901.  Cholecystotomy;  several  stones  removed 
from  the  gall-bladder,  and  firm  adhesions  between  the  gall-bladder 
and  pylorus  separated. 

After-History. — The  patient  made  a  good  recovery. 

Cholecystitis  with  Hypertrophy  :  Cholecystectomy. 

Case  362. — Robert  A.,  aged  thirty-eight,  seen  at  the  Leeds 
General  Infirmary.  For  three  months  had  many  very  severe 
attacks  of  biliary  colic,  and  on  one  occasion  was  deeply  jaundiced. 
Lately  he  had  lost  ij  stones  in  weight.  No  enlargement  of 
the  gall-bladder  to  be  felt,  but  great  tenderness  present  on 
pressure. 

Operation. — 19/3/1901.  Gall-bladder  buried  in  many  adhesions, 
among  which  was  some  recent  yellow  lymph  ;  these  adhesions 
were  separated  and  the  gall-bladder  exposed  ;  in  places  the  walls 
of  the  gall-bladder  were  half  an  inch  thick.  Cholecystectomy  was 
performed,  the  cystic  duct  being  compressed  by  a  clamp,  which 
wxas  removed  in  seventy-two  hours. 

After-History. — Patient  made  a  good  recovery,  and  remains 
well. 

Gall-stones,  Jaundice  :  Dnodeno-cholcdochotomy. 

Case  363. — Hannah  S.,  aged  forty-nine,  seen  at  the  Leeds 
General  Infirmary.  For  six  years  colic  had  persisted,  with 
varying  jaundice. 

Operation. — 22/3/1901.  Duodeno-choledochotomy  ;  eight  large 
and  some  small  stones  removed  from  the  common  duct. 

After -History.  —  Good  recovery;  the  patient  was  well  some 
months  later. 

Gall-stone :  Cholecystotomy ;  Gastrolysis. 

Case  364. — Mrs.  K.,  aged  thirty-six,  seen  with  Dr.  Mallett, 
Bolton.  Patient  had  suffered  from  attacks  of  pain  in  the  right 
hypochondrium  for  fifteen  months;  she  had  never  been  jaundiced; 


416    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

the  pain  was  relieved  by  vomiting,  but  did  not  bear  any  relation 
to  food.  There  was  a  tumour  on  the  right  side  continuous  with 
an  elongated  right  lobe  of  the  liver.  Some  dilatation  of  the 
stomach  and  a  movable  right  kidney  were  present. 

Operation. — 28/3/1 901.  Cholecystotomy  ;  one  stone  impacted 
in  the  cystic  duct  removed  ;  gastrolysis. 

After -History. — The  patient  made  a  good  recovery,  and  was 
well  in  June,  1903. 

Gall-stones :  Cholecystotomy. 

Case  365. — Ada  B.,  aged  thirty-eight,  admitted  to  the  General 
Infirmary,  March  27,  1901.  For  six  or  seven  years  had  had 
attacks  of  pain  in  the  epigastrium.  Seven  weeks  ago  she  had  a 
very  violent  attack  of  pain  in  the  right  hypochondrium,  accom- 
panied by  vomiting  and  jaundice. 

Operation. — 4/4/1 901.  Many  adhesions  around  the  gall-bladder 
separated  ;  cholecystotomy  ;  eight  stones  removed. 

After-History. — Good  recovery. 

Catarrh  of  Gall-bladder  :  Cholecystotomy. 

Case  366. — Mr.  A.,  aged  fifty-one,  seen  with  Dr.  Metcalf,  York. 
Nine  months  ago  patient  began  to  suffer  from  vomiting  after 
food,  with  some  considerable  pain  in  the  upper  part  of  the 
abdomen  and  loss  of  flesh  ;  recently  there  had  been  slight 
jaundice ;  gall-bladder  enlarged,  and  stomach  somewhat  dilated. 

Operation. — 12/4/1901.  Cholecystotomy;  gall-bladder  distended; 
no  gall-stones  found  ;  many  adhesions. 

After  History. — Patient  recovered,  and  was  perfectly  well  for 
some  time  ;  when  heard  of  early  in  1903  he  was  said  to  be 
suffering  from  growth  in  the  caecum,  but  there  had  been  no  more 
gall-stone  seizures. 

Cholelithiasis,  Carcinoma  of  the  Gall-bladder  :  Cholecystectomy  ;  Partial 

Hepatectomy. 

Case  367. — Elizabeth  H.,  aged  thirty-seven,  seen  at  the  Leeds 
General  Infirmary.     (See  p.  190.) 

Gall-stones :  Cholecystotomy. 

Case  368.  —  Enoch  P.,  aged  twenty- two,  admitted  to  the 
General  Infirmary,  April  3,  1901.  Up  to  eighteen  months  ago 
was  quite  well  ;  since  then  has  had  monthly  attacks  of  pain 
below  the  right  costal  margin  and  in  the  epigastrium  ;  had  lost  a 
stone  in  weight  during  the  last  two  months,  and  the  attacks  were 
becoming  more  frequent  and  more  severe  ;  no  jaundice  ;  frequent 


APPENDIX  417 

vomiting;  while  in  the  hospital  had  an  attack  of  pain,  followed  by 
profuse  vomiting  and  jaundice. 

Operation. — 18/4/1901.     Cholecystotomy  ;  568  stones  removed. 

Aftev-Histovy, — Good  recovery. 

Cancer  of  the  Gall-bladder  and  Liver  :  Exploratory  Operation. 

Case  369. — Mary  D.,  aged  thirty,  admitted  to  the  General 
Infirmary,  April  20,  1901.  Two  years  ago  ovariotomy  performed  ; 
during  the  last  five  weeks  the  patient  had  suffered  from  pain  in 
the  right  hypochondrium,  with  some  cough  and  difficulty  in 
breathing ;  pain  bore  no  relation  to  food  ;  considerable  loss  of 
weight. 

Operation.  —  23/4/1901.  Exploratory;  extensive  malignant 
disease  of  the  gall-bladder  and  liver  found. 

After -History.  —  Good  recovery  from  the  operation;  patient 
returned  home. 

Gall-stone,  Cancer  of  Gall-bladder  and  Liver  :  Cholecystectomy  and 

Hepatectomy. 

Case  370. — Mrs.  W.,  aged  fifty-six,  seen  with  Dr.  Gordon 
Black,  Harrogate.  Patient  had  suffered  from  pain  in  the  upper 
abdominal  region  for  some  time,  but  had  never  suffered  from 
jaundice ;  during  the  last  few  weeks  a  tumour  had  appeared  in 
connection  with  the  liver,  was  associated  with  severe  pain  and 
jaundice. 

Operation. — 30/5/1 901.  Cholecystectomy  and  partial  hepatec- 
tomy ;  gall-bladder  infiltrated  with  malignant  disease,  which  was 
spreading  to  the  liver ;  one  large  stone  in  the  gall-bladder.  The 
gall-bladder,  with  a  wedge-shaped  portion  of  the  liver,  removed. 

After-History. — Patient  survived  the  operation  for  several  weeks, 
but  gradually  sank  from  exhaustion.  The  jaundice  increased, 
evidently  from  secondary  growth,  though  no  evidence  of  it  at  time 
of  operation. 

Gall-stones :  Cholecystotomy. 

Case  371. — Alice  H.,  aged  thirty-four,  admitted  to  the  General 
Infirmary,  June  4,  1901.  For  nine  years  had  had  attacks  of  pain 
in  the  right  side  of  the  abdomen ;  lately  the  attacks  had  been 
more  frequent  and  severe,  accompanied  by  slight  jaundice. 

Operation. — 6/6/1 901.  Cholecystotomy;  twenty  small  stones 
removed. 

After -History. — Good  recovery. 

Gall-stones  {Cancer  of  Pylorus) :  Cholecystectomy  and  Pylorectomy. 
Case  372.— Mr.  M.,  aged  fifty-four,  seen  with  Dr.  Grimoldby, 
Grimsby.     He  was  quite  well  up  to  four  months  ago  ;  after  a 

27 


4i8    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 

chill  he  commenced  with  stomach  symptoms  and  vomiting ; 
there  has  been  some  pain  after  food,  but  never  severe;  no  haemate- 
mesis,  no  jaundice,  and  no  tumour  to  be  felt ;  considerable  dilata- 
tion of  the  stomach  and  loss  of  flesh. 

Operation. — 6/6/1 901.  Cholecystotomy  and  pylorectomy  ;  gall- 
bladder full  of  gall-stones,  with  firm  adhesions  to  the  pylorus, 
which  formed  a  distinct  tumour  (cancer  ?),  and  was  stenosed  ; 
fistula  between  the  gall-bladder  and  duodenum  was  found  ;  the 
gall-stones  were  removed,  the  gall-bladder  was  drained,  and  the 
duodenal  fistula  was  closed. 

After -History. — Some  shock  for  twenty-four  hours,  then  steady 
improvement,  but  temperature  was  never  above  970  F.  from  time  of 
admission  until  sudden  death  from  heart  failure  on  the  eighth 
day  ;  the  abdomen  remained  flat,  and  there  were  no  signs  of 
peritonitis. 

Gall-stones :  Cholecystotomy. 

Case  373. — Mr.  G.,  aged  forty-four,  seen  with  Dr.  Topham, 
Halifax.  For  about  three  years  the  patient  had  been  subject  to 
attacks  of  pain  over  the  gall-bladder,  passing  beneath  the  right 
shoulder-blade ;  the  gall-bladder  had  been  noticed  to  be  enlarged 
after  an  attack  ;  there  had  been  no  shivering  and  no  deep  jaundice; 
no  tumour  present,  but  decided  tenderness  over  the  gall-bladder. 

Operation. — 7/6/1901.  Cholecystotomy;  firm  adhesions  between 
the  gall-bladder,  colon,  and  stomach  ;  thirty-four  gall  ••  stones 
removed  from  the  gall-bladder. 

After-History. — Good  recovery. 

Gall-stone  in  Common  Duct :  C holed ochotomy  and  Cholecystotomy. 

Case  374. — Miss  W.,  aged  twenty-nine,  seen  with  Dr.  Graham, 
Cockermouth.  Patient  was  well  for  some  months  following  the 
last  operation,  with  the  exception  of  a  mucous  fistula  ;  recurrence 
of  jaundice  and  pain  took  place,  accompanied  by  fever  and  rigors. 

Operation. — 7/6/1901.  Choledochotomy ;  one  round  stone  re- 
moved from  the  common  duct ;  cholecystotomy  for  the  drainage 
of  the  gall-bladder. 

After -History.  —  Good  recovery.     Well,  October,  1903. 

Gall-stones  in  Common  Duct,  Calcareous  Gall-hladder :  Choledochotomy ; 

Cholecystectomy. 

Case  375. — Mrs.  W.,  aged  fifty-seven,  seen  with  Dr.  Mallett, 
Bolton.  There  had  been  many  attacks  of  biliary  colic,  and 
jaundice  had  been  present  for  three  weeks;  rapid  loss  of  flesh. 

Operation. — 8/9/1901.  Choledochotomy  and  cholecystectomy; 
one  gall-stone  removed  from  the  common  duct,  and  one  from  the 


APPENDIX  419 

gall-bladder ;    the   gall-bladder   was    calcareous,   forming   a    hard 
tumour. 

After-History. — The  patient  made  a  good  recovery,  and  was 
very  well,  June,  1903. 

Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 
Chokdochotomy  and  Cholecystotomy. 

Case  376. — Mrs.  S.,  aged  forty,  seen  with  Dr.  F.  W.  A.  God- 
frey, Scarborough.  For  three  years  she  had  suffered  from  colic 
and  jaundice  ;  jaundice  and  infective  cholangitis  were  present. 

Operation. — 17/6/1901.  Choledochotomy  and  cholecystotomy  ; 
eight  stones  removed  from  the  gallbladder,  and  one  from  the 
common  duct. 

After-History. — The  patient  made  a  good  recovery  from  the 
operation,  and  was  well  in  March,  1903. 

Biliary  Fistula,  Gall  stones  in  Common  Duct :  Choledochotomy. 

Case  377. — Mrs.  T.,  aged  forty-eight,  seen  with  Dr.  T.  Wake 
field,  London.  Colic  had  persisted  for  one  year,  and  there  was 
jaundice ;  there  was  a  biliary  fistula,  the  result  of  a  previous 
operation  performed  elsewhere  in  October,  1900,  when  two  stones 
were  found  in  the  cystic  duct ;  slight  jaundice  and  rigors  occurred 
if  the  fistula  was  not  kept  patent. 

Operation. — 1/7/1901.  Choledochotomy,  with  excision  of  the 
fistula ;  two  stones  were  removed  from  the  common  duct. 

After-History. — Good  recovery,   and    the   patient   is    now  well 

(I903)- 

Gall-stones,  Pericholangitis  with  Abscess  :  Cholecystotomy. 

Case  378. — Mrs.  S.,  aged  forty-five,  seen  with  Dr.  Latouche, 
Ossett.  Frequent  gall-stone  attacks  up  to  ten  years  ago,  then  free 
for  a  period  of  several  years  ;  during  the  last  six  months  the  attacks 
had  been  severe,  and  associated  with  a  distended  gall-bladder  ; 
patient  extremely  weak  ;  a  fluctuating,  tender  swelling,  occupy- 
ing the  right  hypochondrium,  could  be  felt. 

Operation. — 9/7/1901.  Cholecystotomy;  a  large  intraperitoneal 
abscess  around  the  gall-bladder  ;  several  stones  removed  from  the 
gall-bladder,  wThich  was  drained  ;  the  abdomen  was  also  drained 
separately. 

After-History. — The  patient  made  a  good  recovery. 

Actinomycosis  of  the  Gall-bladder  :  Cholecystotomy. 

Case  379. — Fred  N.,  aged  forty-seven,  seen  at  the  Leeds 
General  Infirmary.     (See  p.  173.) 

?7—2 


420    DISEASES  OF  THE  GALL-BLADDER  AND  BILE  DUCTS 

Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 
Choledochotomy  and  Cholecystotomy. 

Case  380. — Annie  F.,  aged  forty-seven,  seen  at  the  General 
Infirmary.  For  five  years  she  had  suffered  from  colic  and 
jaundice  with  ague-like  seizures  ;  the  jaundice  was  intensified  after 
each  attack. 

Choledochotomy  and  cholecystotomy,  for  the  removal  of  gall- 
stones, performed  on  July  ig,  1901,  resulted  in  a  good  recovery, 
and  the  patient  was  well  in  December. 

Biliary  Fistula,  Gall-stone  in  Common  Duct :  Choledochotomy. 

Case  381. — Mrs.  S.,  aged  thirty,  seen  with  Dr.  F.  C.  Sprawson, 
Blackpool.  Cholecystotomy  for  gall-stone  colic,  followed  by 
jaundice,  had  been  performed  in  February,  1900,  elsewhere;  there 
was  a  biliary  fistula  with  jaundice  if  the  fistula  was  not  kept 
patent. 

Operation. — 20/7/1901.  Choledochotomy  and  cholecystotomy  ; 
one  stone  removed  from  the  common  duct. 

After-History. — The  patient  made  a  good  recovery,  and  was 
well  in  November,  1901. 

Gall-stones  in  Common  Duct,  Infective  Cholangitis,  Deep  Jaundice, 
Incessant  Vomiting,  Heart  Disease  :  Choledochotomy. 

Case  382. — Mrs.  H  ,  aged  thirty-eight,  seen  with  Dr.  H.  J. 
Robson,  Leeds.  History  of  spasms,  infective  cholangitis  and 
jaundice,  extending  over  some  years  ;  high  temperature  and  inces- 
sant vomiting  for  a  week  before  operation.  The  patient  was 
extremely  feeble.  There  were  infective  cholangitis,  vomiting, 
heart  disease,  and  deep  jaundice. 

Operation. — 21/7/1901.  Choledochotomy;  several  stones  removed 
from  the  common  duct. 

After-History. — The  patient  took  ether  badly,  becoming  very 
livid  and  almost  pulseless,  and  death  resulted  from  shock. 

Cancer  of  Liver  :  Exploratory  Operation. 

Case  383. — Mrs.  W.,  aged  forty-four,  seen  with  Dr.  Jefferies, 
Bolton.  Twenty  years'  history  of  gall  -  stones  ;  remission  of 
symptoms  for  several  years  ;  lately  recurrence  of  pain  over  the 
gall-bladder.  During  the  last  few  weeks  a  tumour  in  connection 
with  the  liver  has  been  noticed.  No  jaundice  present,  but  loss  of 
flesh. 

Operation. — 24/7/1901.      Kxploratory  ;  cancer  of  the  liver  found. 

After-History.—  Recovery  from  operation,  and  returned  home. 


APPENDIX  421 

Gall-stones  in  Common  Duct,  Deep  Jaundice,  Chronic  Pancreatitis: 
Cholcdochotomy ;    Cholecystotomy. 

Case  384.— Mr.  W.,  aged  forty,  seen  with  Dr.  C.  H.  Taylor, 
Derby.  Patient  had  had  indigestion  and  pain  for  a  year  ;  there 
had  been  loss  of  weight  and  deep  jaundice  for  five  weeks.  Fine 
pancreatic  crystals  found. 

Operation. — 30/7/1 901.  Choledochotomy  and  cholecystotomy  ; 
five  stones  removed  from  the  common  duct,  and  355  from  the 
gall-bladder ;  pancreas  enlarged. 

After-History. — The  patient  went  home  with  a  small  tube  in 
the  sinus ;  he  had  lost  his  jaundice  and  was  well  in  January,  1902. 

Gall-stones  in  Common  Duct,  Pyloric  Stenosis  with  Dilatation  of  the 
Stomach  :  Choledochotomy  ;  Cholecystectomy  ;  Pyloroplasty. 

Case  385. — Miss  T.,  aged  forty-five,  seen  with  Dr.  N.  Williams, 
Harrogate.  There  had  been  gastric  ulcer  for  two  years ;  colic 
and  jaundice  were  present ;  there  was  loss  of  weight  and  strength, 
together  with  pyloric  stenosis  and  dilatation  of  the  stomach. 

Operation. — 5/8/1 901.  Choledochotomy,  partial  cholecystec- 
tomy, and  pyloroplasty  ;  twenty  gall-stones  removed  from  the  gall- 
bladder, and  two  from  the  common  duct. 

After-History. — The  patient  made  a  good  recovery,  and  was  well 
in  November,  1901,  having  gained  normal  weight. 

Gall-stone  in  Common  Duct,  Jaundice,  Chronic  Pancreatitis  :  Chole- 
dochotomy and  Cholecystotomy. 

Case  386. — Mr.  F.,  aged  forty-six,  seen  with  Dr.  R.  H.  Luce, 
Derby.  For  four  months  colic  and  jaundice  had  been  present, 
and  there  was  loss  of  weight ;  jaundice  very  deep  indeed.  Fine 
pancreatic  crystals  found. 

Operation. — 8/8/1 901.  Choledochotomy  and  cholecystotomy  ; 
one  stone  removed  from  the  common  duct,  and  two  from  the  gall- 
bladder ;  head  of  pancreas  swollen  from  chronic  pancreatitis. 

After-History. — Good  recovery  ;  the  patient  was  well  in  Novem- 
ber, 1901. 

Gall-stones  in  Common  Duct,  Cancer  of  Head  of  Pancreas  :  Chole- 
dochotomy ;  Cholecystotomy. 

Case  387. — Mr.  M.,  aged  sixty-two,  seen  with  Dr.  J.  Lawrence, 
Darlington.  For  two  years  colic  had  persisted,  and  for  a  year 
jaundice  had  been  present ;  loss  of  weight  was  complained  of  to 
the  amount  of  5  stones  ;  cholecystenterostomy  had  been  performed 
previously  by  another  surgeon  with  temporary  improvement  ; 
relapse  and  recurrence  of  jaundice,  which  had  continued  ;  great 
loss  of  flesh  and  strength  had  taken  place.  Coarse  pancreatic 
crystals  found. 


422    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation.  —  8/8/1901.  Choledochotomy  and  cholecystotomy  ; 
three  stones  removed  from  the  common  duct,  and  many  from  the 
gall-bladder  ;  cancer  of  the  head  of  the  pancreas ;  anterior  drain- 
age adopted. 

After-History. — The  patient  was  relieved  of  the  pain  and  jaundice, 
and  returned  home  within  the  month  ;  gradual  loss  of  strength, 
due  to  cancer  of  the  pancreas,  ended  in  death  in  October,  1901. 

Gall-stones  in  Common  Duct,  Jaundice,  and  Infective  Cholangitis  : 
Choledochotomy  and  Cholecystotomy. 

Case  388. — Miss  M.,  aged  fifty,  seen  with  Dr.  J.  C.  Wilson, 
Haworth.  The  patient  had  had  spasms  and  jaundice  for  years; 
there  were  ague-like  attacks,  loss  of  flesh,  infective  cholangitis 
and  jaundice. 

Operation. — 1/9/1901.  Choledochotomy  and  cholecystotomy  ; 
one  stone  removed  from  the  gall-bladder,  and  five  from  the  common 
duct  ;  lumbar  drainage  was  employed. 

After-History. — Good  recovery  ;  the  patient  was  well  at  the  end 
of  1901. 

Gall-stones  :  Cholecystotomy. 

Case  389. — Clara  H.,  aged  twenty-seven,  admitted  to  the 
General  Infirmary,  August  26,  1901.  Sixteen  months  ago  had  a 
severe  attack  of  pain  in  the  epigastrium  with  vomiting  ;  was  quite 
free  from  symptoms  for  six  months,  when  she  had  another  attack, 
followed  by  jaundice  ;  the  jaundice  passed  off,  but  the  attacks  had 
recurred  almost  weekly  since,  and  were  more  severe  ;  about  twenty 
stones  had  been  passed  in  the  motions. 

Operation. — 5/9/1901.  Cholecystotomy;  thirteen  small-stones 
removed. 

After-History. — Good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  390. — J.  A.,  aged  sixty,  admitted  to  the  infirmary,  Sep- 
tember 2,  1 90 1.  He  had  suffered  from  attacks  of  biliary  colic  for 
several  years  ;  during  the  last  thirteen  weeks  had  had  eight  severe 
attacks,  all  followed  by  jaundice  ;  loss  of  flesh  lately,  amounting  to 
2  stones  ;  swelling  above  right  costal  margin,  tenderness  above  the 
umbilicus  ;  slight  jaundice. 

Operation. — 12/9/1901.  Cholecystotomy;  two  gall-stones  re- 
moved; drainage. 

After-History. — Good  recovery. 

Cholecystitis  and  Chronic  Catarrh  :  Cholecystotomy  and  Nephropexy. 

Case  391. — Mrs.  N.,  aged  thirty-seven,  seen  with  Dr.  Clayton, 
Wakefield  .     Patient  had  complained  of  pain  over  the  right  side  of 


APPENDIX  423 

the  abdomen,  associated  with  a  tumour,  for  two  years  ;  the  attacks 
were  worse  during  menstruation ;  she  had  never  been  jaundiced, 
but  had  lost  weight  lately  and  become  anaemic ;  tenderness  under 
the  right  costal  margin,  and  fulness  over  the  gall-bladder  region, 
but  no  definite  tumour  ;  kidney  very  mobile. 

Operation.  —  24/9/1901.  Cholecystotomy  and  nephropexy  ; 
cholecystitis  present,  but  no  gall-stones. 

Aftcv-Histovy. — Patient  made  a  good  recovery. 

Catarrhal  Cholecystitis  with  Adhesions,  Movable  Kidney  :  Chole- 
cystotomy; Nephropexy. 

Case  392. — Susan  E.,  aged  forty-two,  admitted  to  the  infirmary, 
September  21,  1 901,  complaining  of  continuous  aching  pain  above 
the  right  costal  margin,  and  sometimes  in  the  shoulder.  No  jaun- 
dice, but  frequently  ague-like  attacks  ;  some  pain  in  the  right  loin  ; 
also  tenderness  over  gall-bladder  ;  no  tumour  to  be  felt  ;  right 
kidney  movable  and  tender. 

Operation. — 26/9/1901.  Gall-bladder  distended  and  thickened; 
adhesions  around  cystic  duct  separated  ;  cholecystotomy  ;  kidney 
exposed  by  lumbar  incision  ;  nephropexy. 

After-History. — Good  recovery. 

Jaundice,  Suppurative  Cholangitis,  General  Peritonitis,  Phlegmonous 
Cholecystitis  :  Drainage. 

Case  393. — Mrs.  A.,  aged  forty-five,  seen  with  Dr.  Moore, 
Holbeck,  for  general  peritonitis,  following  on  cholelithiasis  ;  jaun- 
dice, with  phlegmonous  cholecystitis  and  suppurative  cholangitis; 
patient  too  ill  to  bear  any  extensive  operation. 

Operation. — 29/9/1 901.  Abdomen  drained  and  a  quantity  of 
pus  and  bile  evacuated. 

After-History. — Death  the  next  day  from  exhaustion  due  to  con- 
tinuance of  the  septic  symptoms. 

Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis,  Chronic 
Pancreatitis  :  Choledochotomy. 

Case  394. — Mr.  B.,  aged  fifty-one,  seen  with  Dr.  W.  C.  D.  Hills, 
of  Upwell,  Wisbeach.  There  had  been  only  slight  colic,  but  deep 
jaundice  for  a  year,  and  great  wasting,  with  fever,  rigors,  and 
other  signs  of  infective  cholangitis. 

Operation. — 29/9/1 901.  Choledochotomy  ;  five  stones  removed 
from  the  common  duct ;  the  duct  was  drained,  and  a  lumbar  drain 
was  also  used  ;  there  was  chronic  pancreatitis. 

After -History. — Good  recovery  ;  he  had  gained  1  stone  3  pounds 
in  weight  in  November,  1901  ;  well,  1903. 


424    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stone  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  :  Chole- 
dochotomy  and  Cholecystotomy. 

Case  395. — Mrs.  L.,  aged  thirty,  seen  with  Dr.  Hopkins, 
Leeds.  Patient  was  well  after  the  previous  operation  till  three 
months  ago,  when  she  had  a  recurrence  of  pain,  followed  by  jaun- 
dice, chills,  and  fever. 

Operation. — 29/9/1901.  Cholecystotomy  and  choledochotomy  ; 
one  stone  removed  from  the  gall-bladder,  and  one  from  the 
common  duct. 

After-History. — Good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  396. — Miss  T.,  aged  twenty-two,  seen  with  Dr.  Williams, 
Barrow.  Three  severe  attacks  of  biliary  colic  during  the  last 
six  months,  and  several  minor  attacks  ;  some  loss  of  flesh  and 
jaundice  after  the  last  two  attacks  ;  some  tenderness  over  the  gall- 
bladder, but  no  tumour  ;  movable  right  kidney. 

Operation. — 30/9/1901.  Cholecystotomy;  several  small  stones 
removed  from  the  gall-bladder  and  cystic  duct. 

After-History. — Patient  made  a  good  recovery,  and  was  well, 
October,  1903. 

Chronic  Pancreatitis,  Biliary  Fistula  :  Cholecy stenter ostomy . 

Case  397. — Robert  H.,  aged  twenty-seven,  seen  at  the  Leeds 
General  Infirmary.  (See  Case  336.)  After  the  previous  operation 
the  patient  was  well  for  some  months,  except  for  slight  jaundice, 
and  recently  there  had  been  a  little  discharge  of  bile  from  the 
fistula,  which  he  wished  to  have  cured  on  account  of  the  incon- 
venience. 

Operation. — 3/10/1901.  Cholecystenterostomy  ;  sinus  dissected 
out  and  the  fundus  of  the  gall-bladder  connected  to  the  transverse 
colon  by  a  Murphy's  button. 

After -History. — Patient  made  a  good  recovery  from  the  opera- 
tion, left  the  infirmary  looking  much  better,  and  when  heard  of 
later  was  following  his  occupation. 

Gall-stone  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 

Choledochotomy. 

Case  398. — Charles  P.,  aged  fifty-three,  seen  at  the  Leeds 
General  Infirmary.  Twelve  years  ago  patient  had  had  a  first 
attack  of  biliary  colic ;  for  the  two  years  before  admission  the 
attacks  had  been  frequent,  and  were  always  followed  by  jaundice, 
and  rigors  ;  he  had  lost  6  stones  in  weight.  Jaundice  had  increased 
in  intensity  after  each  attack  ;  slight  enlargement  of  the  liver;  no 
enlargement  of  the  gall-bladder.     Pancreatic  crystals  found. 


APPENDIX  425 

Operation.  —  io/io/igoi.  Choledochotomy  ;  one  large  stone  re- 
moved from  the  common  duct,  which  was  drained  by  a  tube 
stitched  into  the  opening  ;  head  of  pancreas  swollen. 

After-History. — Patient  made  a  good  recovery. 

Empyema  of  Gall-bladder  with  Abscess  of  Liver,  Gall-stones  :  Chole-  ' 

cystotomy,  Hepatotomy. 

Case  399. — George  S.,  aged  thirty-nine,  seen  with  Dr.  Taylor, 
of  Scarborough,  October  14,  1901.  Attacks  of  biliary  colic  for 
five  or  six  years,  always  followed  by  jaundice  ;  loss  of  weight  after 
each  attack  ;  lately  the  attacks  had  been  more  severe. 

Operation. — 15/10/1901.  Gall-bladder  very  adherent  to  pylorus 
and  colon  ;  cavity  in  liver  communicating  with  gall-bladder,  con- 
taining fifty  moderate-sized  gall-stones  and  pus  ;  cholecystotomy 
performed  and  abscess  drained. 

After-History.  —  Recovered  from  operation,  but  had  a  biliary 
fistula ;  almost  all  the  bile  escaped  through  the  fistula,  and  when 
it  was  allowed  to  close,  fever  with  shivering  and  vomiting  occurred. 
For  subsequent  history  see  Case  418. 

Gall-stone  in  Common  Duct,  Cirrhosis  of  Liver,  Ascites,  Jaundice, 
Chronic  Pancreatitis  :  Choledochotomy ;  Epiplopexy. 

Case  400. — Mr.  W.,  aged  fifty  eight,  seen  with  Dr.  C.  S.  A.  Rigby, 
Preston.  He  had  had  very  deep  jaundice  for  three  years.  Biliary 
cirrhosis  and  ascites  as  well  as  jaundice  were  present.  Fine 
pancreatic  crystals  found. 

Operation. — 21/10/1901.  Choledochotomy;  one  stone  removed 
from  the  common  duct  ;  the  omentum  was  fixed  to  the  anterior 
abdominal  wall  ;  anterior  drainage  was  employed.  Pancreas 
swollen. 

After-History. — Good  recovery;  well,  June,  1903;  no  return  of 
ascites. 

Gall-stones  :  Cholecystotomy. 

Case  401.  —  Annie  F.,  aged  twenty-nine,  admitted  to  the 
General  Infirmary,  October  22,  1901.  For  two  years  had 
occasional  attacks  of  biliary  colic  ;  during  the  last  six  months  the 
attacks  had  been  more  frequent,  and  were  followed  by  jaundice  and 
some  swelling  in  the  region  of  the  gall-bladder.  Extreme  tender- 
ness over  the  gall-bladder  ;  no  tumour  to  be  detected  ;  no  jaundice 
present. 

Operation. — 24/10/1901.  Cholecystotomy;  one  large,  rounded 
gall-stone  removed  from  the  gall-bladder. 

A  fter-History. — Good  recovery. 


426    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Paroxysmal  Pains,  Adhesions,  Catarrhal  Cholecystitis  :  Cholecystotomy ; 

Gastrolysis. 

Case  402. — Ada  H.,  aged  twenty-two,  admitted  to  the  infirmary, 
October  22,  1901.  For  five  years  had  suffered  from  attacks  of 
pain  in  the  right  hypochondriac  region  extending  to  the  back, 
with  occasional  vomiting.  Had  never  been  jaundiced  ;  pain  bore 
no  relation  to  food  ;  stomach  dilated. 

Operation.  —  24/10/1901.  Gall-bladder  adherent  to  pylorus, 
duodenum,  and  colon  ;  adhesions  divided  ;  cholecystotomy. 

After-History. — Good  recovery. 

Gall-stones  in  Common  Duct,  Chronic  Pancreatitis,  Jaundice  and  Infective 
Cholangitis  :  Choledochotomy. 

Case  403.  —  Ruth  K.,  aged  forty-six,  seen  at  the  General 
Infirmary.  There  was  a  history  of  spasms  years  before,  and  for 
the  last  eight  months  there  had  been  very  little  pain,  but  the 
temperature  rose  from  1030  to  1050  F.  every  night.  Jaundice  and 
infective  cholangitis  were  present.    Fine  pancreatic  crystals  found. 

Operation.  —  7/11/1901.  Choledochotomy;  the  temperature 
dropped  to  normal  on  the  day  of  operation,  and  remained  normal ; 
swelling  of  head  of  pancreas. 

After-History. — The  patient  is  now  well. 

Chronic  Catarrhal  Cholecystitis  :  Cholecystotomy. 

Case  404. — James  W.,  aged  thirty-eight,  seen  at  the  Leeds 
General  Infirmary.  For  fifteen  years  had  had  occasional  attacks 
of  biliary  colic  ;  lately  the  attacks  had  become  more  frequent. 
There  was  no  jaundice  on  admission,  but  the  patient  stated  that 
he  had  been  jaundiced  occasionally. 

Operation. — 21/11/1901.  Cholecystotomy  for  chronic  catarrh; 
gall-bladder  adherent  and  contracted  ;  no  gall-stones  found. 

After-History. — Patient  made  a  good  recovery. 

Gall-stones  in  Common  Duct,  Chronic  Pancreatitis :  Choledochotomy  and 

Cholecystotomy. 

Case  405. — Miss  S.,  aged  fifty-two,  seen  with  Dr.  C.  Brook, 
Lincoln.  There  had  been  spasms  for  years  and  jaundice  for  four 
months  ;  the  pancreas  was  swollen  from  chronic  pancreatitis. 

Operation. — 30/11/1901.  Choledochotomy  and  cholecystotomy; 
sixty-five  gall-stones  removed, including  eighteen  from  the  common 
duct. 

After- LI istory. — Patient  made  a  good  recovery,  and  remains  well. 

Gall-stones  in  Common  Duct,  Jaundice,  Infective  Cholangitis  and  Chronic 
Pancreatitis  :  Choledochotomy  and  Cholecystotomy. 

Case  406.  John  I).,  aged  forty-eight,  seen  at  the  General 
Infirmary.     He  was  a  stout,  unhealthy  subject,  with  a  history  of 


APPENDIX  427 

former  intemperance.  He  had  suffered  from  gall-stones  for 
twenty  years,  and  from  jaundice  with  infective  cholangitis  since 
May,  1  go  1.     Crowds  of  fine  pancreatic  crystals  found. 

Operation. — 7/12/1901.  Choledochotomy  ;  126  gall-stones  were 
removed  from  the  gall-bladder,  and  88  from  the  common  and 
hepatic  ducts  ;  head  of  pancreas  swollen. 

After-History. — Recovery  was  retarded  by  bronchitis,  but  the 
patient  was  discharged  well  in  five  weeks.      Well,  1903. 

Gall-stones  :  Cholelithotrity ;  Gastrolysis. 

Cash  407. — Alfred  C,  aged  fifty-five,  admitted  to  the  General 
Infirmary,  December  1,  1901.  Twenty-seven  years  ago  was 
troubled  with  attacks  of  abdominal  pain,  which  were  followed  and 
relieved  by  vomiting.  He  was  free  from  trouble  up  to  twelve 
years  ago,  since  when  he  had  had  attacks  of  pain  in  the  abdomen 
every  few  months.  The  pain  began  in  the  lower  part  of  the 
abdomen,  then  passed  into  the  epigastrium,  running  through  to 
the  back  and  shoulder,  and  always  accompanied  by  vomiting, 
which  was  copious,  but  never  contained  blood  ;  pain  bore  no 
relation  to  food,  and  patient  was  never  jaundiced ;  some  tender- 
ness in  the  epigastrium  ;  no  enlargement  of  the  gall-bladder ;  no 
dilatation  of  the  stomach. 

Operation. — 22/12/1901.  Exploratory  laparotomy;  adhesions 
between  the  gall-bladder  and  stomach  divided;  liver  very  cirrhosed ; 
some  gall-stones  crushed  in  the  gall-bladder. 

After-History. — Good  recovery. 

Chronic  Catarrh  of  Gall-bladder  :  Cholecystotomy  and  Gastrolysis. 

Case  408. — Mrs.  B.,  aged  forty-six,  seen  with  Dr.  Bates, 
Ilkley.  Attacks  of  pain  over  the  gall-bladder  for  three  years, 
with  indigestion,  flatulence,  and  pain  after  food.  No  tumour  of 
the  gall-bladder  ;  no  jaundice  ;  some  dilatation  of  the  stomach. 

Operation. — 7/1/1902.  Cholecystotomy ;  numerous  and  firm 
pyloric  adhesions  discovered,  but  no  gall-stones. 

After-History.— Patient  made  a  good  recovery  from  the  opera- 
tion, but  has  had  some  digestive  disturbance  since. 

Catarrhal  Cholecystitis,  Stricture  of  Cystic  Duct,  Adhesions  : 
Cholecystotomy ;  Gastrolysis. 

Case  409.  —  Mrs.  E.,  seen  with  Dr.  Curd,  Bath.  Pain 
resembling  gall-stone  attacks  for  many  years,  writh  great  digestive 
disturbance  ;  lately  the  attacks  had  become  so  frequent  that  the 
patient  was  leading  the  life  of  an  invalid.  No  jaundice  and  no 
tumour  ;  some  dilatation  of  the  stomach. 

Operation. — 11/1/ 1902.  Cholecystotomy;  adhesions  between 
the  gall-bladder,  pylorus,  and   liver   detached  ;    the  gall-bladder 


428    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

and  cystic  duct  were  thickened.  No  gall-stones  present  ;  pylorus 
stenosed  and  kinked.  The  sequel  shows  that  the  cystic  duct  was 
strictured,  and  that  cholecystectomy  would  have  been  the  better 
operation. 

After-History. — Patient  made  a  good  recovery  and  the  wound 
healed,  but  a  recurrence  of  pain  necessitated  the  insertion  of 
a  probe  and  the  re-introduction  of  a  small  tube,  which  discharged 
clear  mucus  ;  the  patient  otherwise  was  well,  June,  1903. 

Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 

Choledochotomy. 
Case  410. — Mrs.  G.,   aged  forty-four,  seen   with   Dr.  Wilson 
Smith,  Bath.     (See  p.  99.) 

Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 

Choledochotomy. 

Case  411. — Mr.  W.,  aged  sixty-one,  seen  with  Dr.  Clampitt, 
Bootle.     (See  p.  99.) 

Cholelithiasis,  Gangrenous  Cholecystitis  :  Cholecystectomy. 

Case  412.- — Maria  T.,  aged  forty-seven,  seen  at  the  Leeds 
General  Infirmary.     (See  p.  119.) 

Cholelithiasis  :  Cholecystotomy  ;  Choledochotomy . 

Case  413. — Mr.  T.,  aged  sixty-two,  seen  with  Mr.  Templeton, 
London.     Gall-stones  in  common  duct ;  choledochotomy. 
After-History. — Quite  well,  November,  1903. 

Chronic  Pancreatitis,  Cholecystitis  :  Cholecystectomy  ;  Drainage  of 

Hepatic  Duct. 

Case  414.— Eliza  T.,  aged  fifty-nine,  admitted  to  the  General 
Infirmary,  January  23,  1902.  Two  and  a  half  years  ago  had  had 
attacks  of  abdominal  pain,  with  distension  and  jaundice ;  the 
jaundice  passed  off,  but  similar  attacks  had  frequently  occurred. 
A  week  before  admission  she  had  a  severe  attack  of  pain  in  the 
upper  part  of  the  abdomen,  with  vomiting,  shivering,  and  jaundice; 
tenderness  over  gall-bladder  ;  pancreas  enlarged  and  hard.  Fine 
pancreatic  crystals  found. 

Operation.  —  31/1/1902.  Small,  contracted,  and  thickened 
gall-bladder;  head  of  pancreas  enlarged  and  hard  (chronic 
pancreatitis) ;  cholecystectomy  ;  cystic  duct  drained. 

After-History. — Good  recovery. 

Gall-stones  :  Cholecystotomy. 
Case  415. — Harriet  R.,  aged  fifty-four,  admitted  to  the  General 
Infirmary,  January  28,  1902.     For  twelve  months  had  had  attacks 
of  biliary  colic  ;  during  the  last  two  months  the  attacks  had  been 


APPENDIX  429 

more  frequent  and  severe,  and  she  had  been  occasionally  jaundiced. 
No  enlargement  of  the  gall-bladder  ;  no  jaundice. 

Operation. — 31/1/1902.     Cholecystotomy  ;   122  stones  removed. 

After -History. — Good  recovery. 

Gall-stones  in  Gall-bladder  and  Common  Duct,  Chronic  Pancreatitis  : 
Choledochotomy  and  Cholecystotomy. 

Case  416. — Jane  H.,  aged  forty-nine,  admitted  to  the  infirmary, 
January  27,  1902.  For  twelve  months  had  had  attacks  of  severe 
pain  in  the  upper  part  of  the  abdomen  on  the  left  side,  passing  to 
the  back,  and  at  times  accompanied  by  vomiting  and  jaundice  ; 
considerable  loss  of  flesh.  While  in  the  hospital  the  patient 
had  a  severe  attack  of  biliary  colic,  with  vomiting,  shivering,  and 
jaundice.     Fine  pancreatic  crystals  found. 

Operation. — 14/2/1902.  Small,  shrunken  gall-bladder  found,  con- 
taining six  stones,  which  were  removed  by  cholecystotomy  ;  one 
large  stone  in  the  common  duct  removed  by  choledochotomy  ;  inci- 
sion in  the  duct  sutured  ;  gall-bladder  drained  ;  pancreas  swollen. 

A  iter -History. — Good  recovery. 

Gall-stones  in  Common  Duct :  Choledochotomy. 
Case  417. — Mrs.  D.,  aged  forty-four,  seen  with  Dr.  Temperley 
Grey,  Lenham.     (See  p.  99.) 

Imperfect  Biliary  Fistula,  Almost  Complete  Obliterative  Cholecystitis,  with 
Complete  Stricture  of  the  Common  Bile-duct  :  Exploratory  Operation. 

Case  418.— George  S.,  aged  forty,  seen  at  the  Leeds  General 
Infirmary.  (See  Case  399.)  Since  the  previous  operation  the 
patient  had  been  in  fairly  good  health,  but  the  fistula  was  still 
patent,  and  large  quantities  of  bile  escaped  daily.  The  fistula  had 
a  tendency  to  close,  when  the  patient  had  pain,  with  rise  of  tem- 
perature and  rigors,  until  relief  was  afforded  by  securing  a  free 
flow  of  the  infected  bile. 

Operation. — 20/2/1902.  Many  adhesions  found,  and  the  gall- 
bladder was  contracted  ;  no  gall-stones  discovered. 

After-History. — The  patient  died  four  days  later  from  intestinal 
haemorrhage.  At  the  autopsy  the  common  duct  was  found  to  be 
completely  obliterated  ;  it  would  not  admit  a  small  probe,  nor  could 
the  papilla  be  found.  The  haemorrhage  had  occurred  from  a  point 
in  the  ileum,  within  3  feet  of  the  ileo-caecal  valve,  and  was  appar- 
ently not  related  to  the  gall-bladder  trouble  nor  to  the  operation. 

Gall-stone  in  Ampulla  of  Vater  :  Cholecystotomy ;  Duodeno- 
cholcdochotomy. 

Case  419. — Elizabeth  L.,  aged  fifty-nine,  admitted  to  the 
infirmary,   February   19,   1902.     Three   years    attacks   of  biliary 


430    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

colic  ;  last  Christmas  severe  attack,  followed  by  jaundice,  clay- 
coloured  motions,  loss  of  flesh,  and  frequent  vomiting  ;  enlarge- 
ment and  tenderness  of  gall-bladder ;  jaundice  present.. 

Operation. — 20/2/1902.  Bile-ducts  distended  ;  stone  impacted  at 
ampulla  of  Vater  removed  by  duodeno-chokdochotomy  ;  chole- 
cystotomy  ;  drainage. 

After-History. — Good  recovery;  on  December  17,  1902,  patient 
very  well,  and  had  regained  normal  weight. 

Gall-stones  with  Infective  Cholangitis  :  Cholecystotomy. 

Case  420. — Mrs.  C,  aged  sixty-five,  seen  with  Dr.  Greig, 
Hampstead.  Had  suffered  from  symptoms  of  gall-stones  for 
years,  and  recently  had  had  signs  of  infective  cholangitis  with 
slight  jaundice.  The  attacks  were  at  times  on  the  left  side, 
simulating  angina  pectoris,  and  being  associated  with  vascular 
disturbance. 

Operation. — 22/2/1902.  Cholecystotomy  ;  a  number  of  gall- 
stones were  removed  from  the  gall-bladder  and  ducts. 

After -History. — Patient  made  a  good  recovery,  and  was  able 
to  leave  the  surgical  home  shortly  after  the  month-end  ;  some 
months  subsequently  she  had  several  slight  attacks,  apparently 
due  to  catarrh,  but  they  passed  off  under  general  treatment. 

Gall-stones,  Jaundice,   Chronic   Pancreatitis  :  Cholecystotomy  and 

Choledochotomy. 

Case  421. — Mr.  C,  aged  twenty,  seen  with  Dr.  Stewart, 
Thornton.  The  patient  had  been  jaundiced  off  and  on  for  eight 
years ;  during  that  time  he  had  had  several  distinct  attacks  of 
pain,  the  first  attack  being  two  years  after  the  onset  of  the  jaun- 
dice ;  there  had  been  no  loss  of  flesh ;  the  pulse  was  feeble,  and 
there  was  a  mitral  bruit ;  some  albumin  in  the  urine  ;  slight 
enlargement  of  the  liver  and  enlargement,  with  tenderness,  of  the 
gall-bladder.  The  patient  was  seen  '  three  months  after  the  pre- 
vious notes  had  been  taken,'  just  after  a  severe  attack  of  pain  over 
the  gall-bladder.  The  jaundice  had  become  much  deeper,  and  the 
liver  and  spleen  were  considerably  enlarged.  Fine  pancreatic 
crystals  found. 

Operation. — 25/2/1902.  Cholecystotomy  ;  very  dark  gall-stones 
were  removed  from  the  gall-bladder  and  cystic  duct  ;  some  soft 
stones  crushed  in  the  common  duct,  and  removed  by  scoop  through 
choledochotomy  opening  ;  pancreas  swollen. 

After-History. — The  patient  made  a  good  recovery  from  the 
operation.  A  tube  was  worn  in  the  gall-bladder  for  about  a  year, 
and  through  this  the  ducts  were  irrigated  with  sterilized  oil  ;  the 
patient  ultimately  made  a  good  recovery. 


APPENDIX  43' 

Gall-stones  :  Cholc cystotomy. 

Case  422. — Mrs.  R.,  aged  fifty-two,  seen  with  Dr.  Gregor, 
Crow  Park.  Patient  had  had  symptoms  of  gall-stones  for  several 
years,  and  frequently  recurring  attacks  of  pain,  with  rise  of  tem- 
perature, but  no  jaundice. 

Operation. — 26/2/1902.  Cholecystotomy ;  several  stones  im- 
pacted in  the  cystic  duct  were  removed. 

After-History. — Good  recovery;  well  in  June,  1903.  (See 
Case  528.) 

Gall-stones  :  Cholecystotomy. 

Case  423. — Mary  T.,  aged  sixty-six,  admitted  to  the  infirmary, 
February  24,  1902.  Well  up  to  six  weeks  ago,  when  she  had  a 
severe  attack  of  biliary  colic  ;  since  then  the  attacks  had  been 
more  frequent  and  severe,  and  accompanied  by  vomiting  ;  no 
jaundice,  and  no  enlargement  of  the  gall-bladder. 

Operation. — 27/2/1902.  Cholecystotomy;  several  stones  removed 
from  the  gall-bladder  and  cystic  duct. 

After-History. — Good  recovery. 

Catarrhal  Cholecystitis  :  Laparotomy. 

Case  424. — Ruth  H.,  aged  thirty-three,  admitted  to  the 
infirmary,  February  22,  1902.  Pain  half  an  hour  after  food ; 
never  vomited  blood  ;  attacks  of  pain  in  gall-bladder  region,  accom- 
panied by  swelling  there,  and  usually  followed  by  jaundice,  recently 
by  temperature  and  chills  during  attacks  ;  stomach  not  dilated  ; 
slight  jaundice  present. 

Operation. — 6/3/1902.  Laparotomy;  no  gall-stones  found; 
apparently  catarrhal  cholecystitis. 

After-History. — Good  recovery  ;  well,  1903. 

Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 

Choledochotomy. 

Case  425. — Mrs.  R.,  aged  fifty-two,  seen  with  Dr.  Althorp, 
Bradford.  For  the  past  few  months  the  patient  had  been  suffer- 
ing from  rigors,  with  tingeing  of  the  conjunctivae,  though  no  deep 
jaundice  ;  great  loss  of  flesh  ;  a  tumour  had  been  present  and  some 
dilatation  of  the  stomach  ;  during  the  attacks  the  temperature  had 
risen  to  1030  F.,  and  vomiting  had  been  severe. 

Operation. — 6/3/1902.  Choledochotomy ;  removal  of  several 
gall-stones ;  duct  sutured. 

After -History. — Good  recovery  ;  well,  March,  1903. 

Gall-stones  :  Choledochotomy  and  Cholecystotomy. 

Case  426. — Mrs.  P.,  aged  thirty-seven,  seen  with  Dr.  Haigb, 
Golcar.     For  four  or  five  years  had  suffered  from  attacks  of  biliary 


432    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

colic  ;  the  last  two  attacks  had  been  extremely  severe,  and  were 
followed  by  jaundice;  the  patient  had  just  recovered  from  an 
attack,  and  there  was  a  slight  icteric  tinge ;  some  swelling  over 
the  gall-bladder  present,  with  great  tenderness. 

Operation. — 12/3/1902.  Cholecystotomy :  one  stone  removed 
from  the  gall-bladder ;  choledochotomy  :  one  stone  removed  from 
the  cystic  duct. 

Aftev-History. — The  patient  made  a  good  recovery. 

Gall-stones  in  Common   Duct,  Jaundice  and  Infective  Cholangitis  : 
Choledochotomy  and  Cholecystotomy. 

Case  427.— Mrs.  M.,  aged  sixty,  seen  with  Sir  Dyce  Duck- 
worth, Sir  Henry  Blanc,  and  Dr.  Hort.  History  of  gall-stones 
for  some  years,  with  jaundice  and  infective  cholangitis  for  three 
months  ;  loss  of  flesh  and  strength. 

Operation. — 19/3/1902.  Pus  and  gall-stones  removed  from  the 
gall-bladder  by  cholecystotomy,  and  several  gall-stones  removed 
from  the  common  duct  by  choledochotomy  ;  common  duct  opening 
closed  by  suture  ;  gall-bladder  drained. 

After-History. — Uninterrupted  recovery  ;  patient  well,  1903. 

Gall-stones  :  Cholecystotomy. 

Case  428. — Miss  W.,  aged  thirty-five,  seen  with  Dr.  Scatterty, 
Keighley.  For  some  months  had  suffered  from  attacks  of  biliary 
colic ;  several  gall-stones  had  been  passed,  but  lately  the  attacks 
had  become  more  frequent  and  severe. 

Operation. — 4/4/1902.  Cholecystotomy;  fifteen  stones  removed 
from  the  gall-bladder  and  cystic  duct. 

After-History. — The  patient  made  a  good  recovery,  and  remains 
well. 

Gall-stones,  Jaundice,  Acute  Pancreatitis :  Cholecystotomy. 

Case  429. — Mr.  S.,  seen  with  Dr.  Nettle,  Liskeard.    (Seep.  127.) 

Gall-stones,  Epilepsy,  M  or phino  maniac  :   Cholecystotomy . 

Case  430. — Mrs.  McG.,  aged  forty-eight,  seen  with  Dr.  France, 
Bury.  For  many  years  had  suffered  from  biliary  colic;  several 
years  ago  had  acute  pneumonia,  since  which  time  the  pains  had 
been  more  severe ;  during  several  of  the  attacks  she  had  had 
epileptic  seizures ;  some  gall-stones  had  been  passed,  but  not 
recently.  The  pain  for  several  months  had  recurred  five  or  six 
times  during  the  twenty-four  hours,  and  had  been  so  severe  that 
she  had  become  addicted  to  morphia.  There  had  been  some  dis- 
tension of  the  gall-bladder  and  slight  enlargement  of  the  liver, 
but  no  rigors.    Patient  took  3  grains  of  morphia  at  each  injection. 

Operation. — 8/4/1902.  Cholecystotomy;  contracted  and  thickened 


APPENDIX  433 

gall-bladder ;    some  stones   removed    from   the    gall-bladder  and 
cystic  duct. 

After-History. — Patient  died  a  week  later  from  pneumonia. 

Gall-stone  in  Ampulla  of  Vater,  Cirrhosis  of  Liver :  Duodeno- 
choledochotomy.     Subsequent  Cancer  of  Pancreas  (?). 

Cask  431. — Mr.  E.,  aged  fifty-eight,  seen  with  Dr.  Cooke,  Bath. 
Patient  had  been  subject  to  painful  indigestion  for  a  year  or  two. 
Never  had  severe  pain  until  April,  1900,  when,  after  a  chill,  he 
had  an  attack  of  acute  pain  over  the  liver,  followed  by  jaundice. 
He  had  had  attacks  of  pain  two  or  three  times  since,  followed  by 
deepening  of  the  jaundice  ;  the  last  attack  occurred  three  days 
previously,  and  the  jaundice  persisted.  He  had  lost  considerably 
in  weight.  The  right  lobe  of  the  liver  was  enlarged  and  smooth  ; 
there  was  no  distension  of  the  gall-bladder,  and  no  tenderness 
could  be  elicited. 

Operation. — 8/4/1902.  A  gall-stone  impacted  at  the  ampulla 
was  removed  by  duodeno-choledochotomy,  and  cholecystotomy 
was  performed  for  drainage  ;  hypertrophic  cirrhosis  of  the  liver. 

After-History. — Patient  made  a  good  recovery  from  the  opera- 
tion, though  there  was  some  leakage  from  the  duodenum  for  some 
time.  He  remained  well  for  nearly  a  year,  when  he  had  a 
recurrence  of  jaundice  with  severe  pain,  rapid  enlargement  of  the 
liver,  ascites  and  profuse  hsematemesis,  from  which  he  died  after 
a  short  illness.     I  suspect  cancer  of  the  pancreas  had  supervened. 

Gall-stones  in  Common  Duct,  Jaundice  :  Duodeno-choledochotomy. 

Case  432. — -James  B.,  aged  fifty-four,  admitted  to  the  infirmary, 
April  7,  1902.  Eight  years  ago  had  had  attacks  of  biliary  colic, 
followed  by  jaundice.  He  was  jaundiced  for  a  month,  and  then 
recovered ;  since  then  had  had  frequent  attacks.  Three  weeks 
ago  had  a  very  severe  seizure,  again  followed  by  jaundice,  which 
had  persisted. 

Operation. — 11/4/1902.  Liver  enlarged  and  cirrhosed  ;  gall- 
bladder shrunken  ;  duodeno-choledochotomy ;  forty-seven  gall- 
stones removed  from  the  common  duct ;  duodenum  closed ; 
abdomen  drained. 

After-History. — Good  recovery. 

Acute  Cholecystitis,  Gall-stones  :  Cholecystotomy. 
Case  433. — Mrs.  K.,  aged  forty-eight,  seen  with  Dr.  Coward, 
Huddersneld.     Previous  history  of  gall-bladder  pain  for 'several 
years ;    acute  symptoms,  with   painful    diffuse    swelling   in    gall- 
bladder region  for  ten  days. 

Operation. — 17/4/ 1902.      Inflamed    and   thickened  gall-bladder, 

'   28 


434    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

surrounded  by  adhesions   and   containing    muco-pus   and    gall- 
stones, with  some  impacted  in  the  cystic  duct ;  cholecystotomy 
performed  ;  gall-stones  removed  ;  drainage. 
After -History. — Good  recovery. 

Gall-stones  in  Common  Duct,  Suppurative  Cholangitis  :  Choledochotomy ; 

Cholecystectomy. 

Case  434. — Mrs.  J.,  aged  forty-one,  seen  with  Dr.  Riley,  Sale. 
(See  p.  117.) 

Cholelithiasis  :  Cholecystotomy  ;  Choledochotomy. 

Case  435. — Rose  S.,  aged  fifty-six,  seen  at  the  Leeds  General 
Infirmary,  suffering  from  jaundice,  with  continuous  pain  on  the 
right  side  of  the  abdomen.  The  jaundice  had  been  present  for 
months,  and  she  had  been  subject  to  ague-like  attacks  since 
December,  1901. 

Operation. — 2/5/1902.  Gall-stones  removed  from  the  gall-bladder 
and  common  duct  by  cholecystotomy  and  choledochotomy. 

After-History. — The  patient  made  a  good  recovery,  and  was 
able  to  leave  the  hospital  on  May  28. 

Gall-stones  in  Common  Duct  and  Stricture  of  Papilla :  Choledochotomy 
and  Duodeno -choledochotomy . 

Case  436. — Mrs.  T.,  aged  fifty,  seen  with  Dr.  Lawrence, 
Darlington.     (Seep.  115.) 

Injury  of  Hepatic  Duct. 
Case  437. — Austin   M.,  aged   twenty-five,  seen  at  the   Leeds 
General  Infirmary.     (See  p.  53.) 

Gall-stones  in  Common  Duct,  Chronic  Pancreatitis  :  Choledochotomy. 

Case  438.  —  Mr.  M.,  aged  forty-eight,  seen  with  Dr.  Clifford, 
Stalybridge.  For  five  years  had  been  subject  to  attacks  of  pain 
over  the  liver  and  gall-bladder ;  under  treatment  at  Harrogate 
had  been  greatly  relieved.  There  was  no  persistent  jaundice, 
though  it  recurred  after  each  attack;  during  the  last  three  months 
jaundice  had  been  present,  and  he  had  lost  30  pounds  in  weight. 
He  had  ague- like  attacks  from  time  to  time;  the  liver  was 
enlarged  and  tender  ;  no  enlargement  of  the  gall-bladder  ;  crowds 
of  line  pancreatic  crystals  found. 

Operation. —  13/5/ 1902.  Choledochotomy;  one  gall-stone 
removed  from  the  common  duct;  duct  sutured;  abdomen  drained; 
pancreas  swollen. 

After-History. — Patient  made  a  good  recovery,  and  was  well, 
June,  1903. 


APPENDIX  435 

Gall-stones  in  Common  Duct :  Choledochotomy  and  Clwlecysiotomy. 

Case  439. — Margaret  G.,  aged  fifty-six,  admitted  to  the  General 
Infirmary,  May  8,  1902.  For  thirty  years  had  had  occasional 
attacks  of  biliary  colic ;  lately  the  attacks  had  become  more 
severe,  and  were  followed  by  jaundice,  which  had  persisted 
between  the  seizures;  shivering  attacks  :  loss  of  flesh. 

Operation. —  15/5/1902.  Choledochotomy;  twenty  stones  re- 
moved from  the  common  duct  ;  duct  sutured ;  cholecystotomy  for 
drainage. 

After- History. — The  patient  made  a  good  recovery. 

Typhoidal  Cholecystitis,  with  Suppurative  Cholangitis,  Gall-stones  in 
Hepatic  Duct,  Gall-bladder  duodenal  Fistula  :  Hepato-dochotomy 
and  Drainage  of  Hepatic  Duct. 

Case  440. — Alice  A.,  aged  twenty-four,  admitted  to  the  infirmary,. 
May  5,  1902.  In  September,  1901,  the  patient  had  had  typhoid 
fever,  and  was  in  bed  for  nine  weeks  with  some  complication,  said 
to  be  peritonitis.  Three  weeks  ago  became  deeply  jaundiced,, 
with  attacks  of  severe  pain  in  right  hypochondriac  region  going; 
through  to  the  back ;  jaundice  had  varied  in  intensity  from  time 
to  time,  but  had  never  disappeared  ;  it  was  accompanied  by  high 
temperature,  rigors,  sweating,  and  loss  of  flesh.  No  enlargement 
•of  gall-bladder  or  liver  could  be  felt ;  tenderness  above  and  to  the 
right  of  the  umbilicus.     Patient  thin  and  wasted. 

Operation. — 15/5/1902.    Very  firm  adhesions  around  gall-bladder; 
gall-bladder  duodenal  fistula  ;  gall-bladder  distended  with  offensive 
pus  ;  large  gall-stone  found  in  hepatic  duct  ;  fistula  in  duodenum 
closed  by  sutures.     Hepato-dochotomy;  removal  of  concretion:; 
partial  removal  of  gall-bladder  and  drainage  of  hepatic  duct. 

After-History. — Death  from  shock.  Post-mortem  examination? 
showed  common  and  hepatic  ducts  quite  clear;  no  peritonitis; 
hepatic  duct  dilated,  nearly  an  inch  in  diameter  ;  large  gall-stone 
impacted  in  the  substance  of  the  liver  ;  suppurative  cholangitis. 

Chronic  Catarrh  of  the  Gall-bladder  :  Cholecystotomy;  Hydronephrosis  ; 
Nephrotomy ;  Nephropexy. 

Case  441. — Rose  F.,  aged  forty-two,  seen  at  the  Leeds  General 
Infirmary.  Symptoms  of  pain  on  right  side  of  the  abdomen  for 
twelve  years,  which  were  associated  with  irritability  of  the  bladder. 
More  recently  the  pain  began  in  the  gall  -  bladder  region,  and 
passed  to  the  shoulder.  A  tumour,  clearly  kidney,  could  easily 
be  felt,  and  above  this  could  be  recognised  a  distended  gall- 
bladder. 

Operation. — 1 5/5/1902.  Chronic  catarrh  of  the  gall-bladder  dis- 
covered,   and    cholecystotomy   performed.     The   kidney   tumour 

28— 2 


436    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

proved    to    be   a   hydronephrosis,    for    which    nephrotomy    and 
nephropexy  were  done. 

After-History. — The  patient  made  a  good  recovery,  and  was 
made  an  out-patient  on  June  7. 

Gall-stones :  Cholecystotomy. 

Case  442. — Ann  S.,  aged  forty-five,  admitted  to  the  General 
Infirmary,  May  12,  1902.  For  sixteen  years  attacks  of  biliary 
colic,  lately  loss  of  flesh  and  vomiting  ;  attacks  increasing  in 
severity. 

Operation. — 22/5/1902.     Cholecystotomy  ;  450  stones  removed. 

Aftev-Histovy. — Good  recovery. 

Cholelithiasis,  Jaundice  and  Infective  Cholangitis  :  Choledochotomy  and 

Cholecystotomy. 

Case  443. — Margaret  P.,  aged  thirty-five,  seen  at  the  Leeds 
General  Infirmary,  suffering  from  jaundice  with  infective  cholan- 
gitis, the  jaundice  having  been  present  since  October,  1901,  though 
she  had  been  subject  to  attacks  of  pain  with  distinct  jaundice  since 
July  of  that  year. 

Operation. — 23/5/1902.  Cholecystotomy  performed,  and  three 
large  stones  removed.  A  gall-stone  could  be  felt  floating  in  a 
very  much  enlarged  common  duct  :  this  was  removed  by  chole- 
dochotomy. 

After-History. — The  patient  made  a  good  recovery,  and  was  able 
to  return  home  on  June  14. 

Typhoid  Infection  of  Bile-duct  in  Liver,  Abscess  of  Liver  :  Hepatotomy. 

Case  444. — Stephen  N.,  aged  twenty -five,  admitted  to  the 
General  Infirmary,  May  30,  1902.  A  year  previously  the  patient 
had  had  an  attack  of  enteric  fever  in  South  Africa,  and  was  in  bed 
about  three  weeks.  He  made  a  good  recovery,  and  was  quite 
well  up  to  a  week  ago,  when  a  swelling  was  noticed  in  the  epigas- 
trium, which  was  somewhat  tender  and  painful.  During  the  last 
few  days  the  swelling  had  increased  in  size,  and  become  more 
painful ;  there  had  been  no  sickness,  vomiting,  or  jaundice  ;  very 
slight  rise  of  temperature,  but  no  constitutional  disturbance.  In 
the  subcostal  angle  there  was  a  smooth  swelling,  dull  on  percus- 
sion, which  was  tender  to  pressure.  The  liver  was  enlarged,  but 
there  were  neither  jaundice  nor  dilatation  of  the  stomach. 

Operation. — 30/5/1902.  A  vertical  incision,  2  inches  in  length, 
was  made  over  the  tumour.  On  dividing  the  peritoneum,  an 
abscess  was   opened,   containing   about  4  ounces  of   pus.     The 


APPENDIX  437 

cavity  was  explored,  and  found  to  extend  into  the  left  lobe  of  the 
liver ;  this  was  drained.     No  gall-stones  discovered. 
After-History. — The  patient  made  a  good  recovery. 

Cancer  of  Pancreas  :  Cholecystotomy. 

Case  445. — Mr.  D.,  aged  fifty-nine,  seen  with  Dr.  Levick, 
Middlesborough.  Nine  months  ago  jaundice  came  on  suddenly 
with  pain,  but  no  digestive  disturbance.  Patient  had  never  been 
subject  to  attacks  of  biliary  colic  ;  no  shivering  attacks,  but  great 
loss  of  flesh.  The  liver  was  enlarged  to  the  level  of  the  umbilicus; 
some  enlargement  of  the  gall-bladder  ;  no  ascites  ;  slowly  soluble 
pancreatic  crystals  found  in  urine. 

Operation. — 2/6/1902.  Cholecystotomy  ;  a  hard  mass  in  the 
head  of  the  pancreas,  probably  malignant. 

After-History. — Patient  made  a  good  recovery  from  the  opera- 
tion, and  left  with  a  biliary  fistula.  He  was  greatly  relieved  and 
lived  until  January,  1903. 

Catarrhal  Cholecystitis,  Adhesions  :  Gastrolysis. 

Case  446. — Mary  F.,  aged  forty,  seen  at  the  General  Infirmary, 
May  28,  1902.  For  several  years  had  had  attacks  of  pain  in  the 
abdomen  ;  lately  had  suffered  from  distension  of  the  abdomen, 
with  severe  pain  and  vomiting. 

Operation. — 3/6/1902.  Adhesions  around  the  gall-bladder  and 
pylorus  separated. 

After-History. — Good  recovery. 

Gall-stones,  Jaundice,  and  Infective  Cholangitis  :  Chronic  Pancreatitis  ; 
Choledochotomy  and  Cholecystotomy. 

Case  447. — Mary  M.,  aged  fifty-three,  admitted  to  the  General 
Infirmary,  May  27,  1902.  For  twelve  months  had  had  attacks  of 
biliary  colic  ;  lately  the  attacks  had  been  more  severe,  accom- 
panied by  vomiting,  ague-like  attacks,  and  jaundice.  Patient  had 
lost  flesh  considerably.  Great  tenderness  above  and  to  the  ri^ht 
of  the  umbilicus.     Fine  pancreatic  crystals  found. 

Operation. — 3/6/1902.  Choledochotomy;  stones  removed  from 
the  common  duct ;  cholecystotomy  for  drainage;  swollen  pancreas. 

After-History.  —  Good  recovery. 

Catarrh  of  Gall-bladder  and  (?)  Chronic  Pancreatitis  :  Cholecystotomy. 
Case  448. — Mr.  D.,  aged  sixty-one,  seen  with  Dr.  Pennefather, 
Heme  Hill,  and  Dr.  W.  G.  Fletcher,  London.  For  twelve  years 
patient  had  been  subject  to  attacks  of  pain  over  the  gall-bladder, 
accompanied  by  sickness,  but  no  jaundice.  The  pain  lately  had 
become  more  acute,  and  a  slight  icteric  tinge  was  present.  No 
enlargement  of  the  liver  or  gall-bladder,  but  tenderness  above  the 
umbilicus  elicited. 


438    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation.—  5/6/1902.  Cholecystotomy  ;  gall-bladder  enlarged 
and  thickened,  adherent  to  the  pylorus  and  omentum.  The  adhe- 
sions were  detached,  and  the  gall-bladder  drained.  The  head  of 
the  pancreas  was  a  little  enlarged. 

After- History. — Patient  made  a  good  recovery  from  the  opera- 
tion, but  for  a  time  after  the  drainage  was  given  up  he  had  slight 
recurrences  of  pain,  which  ultimately  cleared  up,  and  in  June,  1903, 
he  was  quite  well. 

Tumour  of  Gall  bladder,  Catarrhal  Cholecystitis  :  Cholecystotomy. 

Case  449. — Ada  McL.,  aged  twenty -nine,  admitted  to  the 
General  Infirmary,  June  10,  1902.  For  four  or  five  years  had 
had  attacks  of  biliary  colic  and  vomiting.  Lately  the  pain  had 
been  constant,  and  the  severe  attacks  had  been  followed  by 
jaundice.  Tenderness  above  and  to  the  right  of  the  umbilicus, 
with  enlargement  of  the  gall-bladder. 

Operation. — 1 8/6/1902.     Cholecystotomy. 

After-History. — Good  recovery. 

Catarrhal  Cholecystitis :  Cholecystotomy. 

Case  450. — Mary  B.,  aged  forty-two,  admitted  to  the  General 
Infirmary,  June  18,  1902.  Eighteen  months  ago  had  attacks  of 
abdominal  pain,  accompanied  by  vomiting,  since  which  time  the 
attacks  had  been  frequent  and  severe  ;  no  jaundice  ;  considerable 
tenderness  above  the  umbilicus  ;  no  dilatation  of  the  stomach. 

Operation. — 24/6/1902.  Chronic  catarrh  of  the  gall-bladder,  but 
no  gall-stones ;  cholecystotomy. 

After -History. — Good  recovery. 

Gall-stones  in  Hepatic  and  Common  Ducts  :  Choledochotomy. 

Case  451. — Mrs.  L.,  aged  seventy,  seen  with  Dr.  Gross, 
Clapham.  Patient  had  had  gall-stone  symptoms  for  three  years, 
and  at  times  jaundice.  Lately  the  attacks  had  become  very 
frequent,  accompanied  by  fever,  ague-like  seizures,  loss  of  flesh, 
and  jaundice.  The  liver  was  slightly  enlarged,  and  there  was 
tenderness  over  the  gall-bladder,  but  no  enlargement  of  it. 

Operation. — 17/7/1902.  Choledochotomy;  numerous  gall-stones 
removed  from  the  common  and  hepatic  ducts ;  duct  sutured  ; 
abdomen  drained. 

After-History. — Patient  made  a  good  recovery,  and  was  well 
some  months  later. 

Gall-stones  in  Hepatic  and  Common  Ducts  :  Choledochotomy. 

Cash  452. — Mrs.  H.,  aged  fifty-two,  seen  with  Dr.  Mercer, 
Ripponden.  Lately  subject  to  attacks  of  pain  after  food.  The 
pain  was  in  the  centre  of  the  epigastrium,  passing  through  to  the 


APPENDIX 


439 


shoulder,  the  symptoms  having  been  intermittent  for  some  time.  A 
week  ago  a  faceted  gall-stone  was  passed,  but  there  had  been  no 
relief,  and  the  pain  had  been  continuous  and  increasing  in  severity, 
with  slight  jaundice.  No  enlargement  of  the  gall-bladder,  except 
during  the  attacks. 

Operation. — 25/7/1902.  Choledochotomy  ;  fifteen  stones  removed 
from  the  common  and  hepatic  ducts  by  means  of  a  scoop  passed 
through  the  incision  in  the  common  duct  ;  abdomen  drained  ;  duct 
sutured. 

After-History. — The  patient  made  a  good  recovery,  and  remains 
well. 

Cholelithiasis,  Empyema  of  Gall-bladder  :  Cholecystoiomy. 

Case  453. — Mrs.  H.,  seen  with  Dr.  Footner,  Tunbridge  Wells. 
For  some  years  had  been  subject  to  spasms,  and  only  lately  had 
the  attacks  been  followed  by  jaundice.  After  an  attack,  more 
acute  than  usual,  a  swelling  developed  in  the  gall-bladder  region  ; 
this  was  associated  with  great  pain,  marked  tenderness,  some 
elevation  of  temperature,  and  slight  jaundice.  As  the  symptoms 
were  getting  worse  and  there  was  clearly  local  peritonitis,  opera- 
tion was  decided  on. 

Operation.  —  30/7/1902.  Cholecystotomy ;  gall-bladder  was 
found  to  be  distended  with  pus,  and  contained  several  gall-stones ; 
others  were  found  impacted  in  the  cystic  duct.  The  gall-bladder 
was  emptied  and  drained  after  the  removal  of  the  gall-stones. 

After-History. — I  had  a  letter  in  1903  from  Dr.  Footner  to  say 
that  the  patient  was  in  very  good  health. 

Cirrhosis  of  Liver,  Ascites,  Jaundice  :  Cholecystotomy  and  Epiplopexy. 

Case  454. — Mrs.  I.,  aged  thirty-two,  seen  with  Dr.  Clampitt, 
Bootle.  Patient  was  quite  well  up  to  five  years  ago,  when  she 
began  to  suffer  from  swelling  of  the  joints  and  general  weakness. 
A  year  ago  began  to  suffer  from  pain  over  the  gall-bladder,  with 
swelling  of  the  abdomen,  loss  of  flesh,  and  diarrhoea.  The  abdo- 
minal swelling  increased  rapidly  ;  lately  the  patient  had  become 
jaundiced ;  the  liver  was  a  little  enlarged  and  cirrhosed,  and  there 
was  some  ascites. 

Operation. — 6/8/1902.  Cholecystotomy  and  epiplopexy  for 
cirrhosis  of  the  liver  ;  gall-bladder  drained. 

After-History. — Patient  recovered  from  the  operation,  but  died 
six  months  later  from  the  progress  of  the  disease. 

Gall-stones  :  Cholecystotomy. 

Case  455. — Mr.  M.,  aged  fifty-seven,  seen  with  Dr.  Spiavvson, 
Blackpool.     For  six  months  had  suffered  from  attacks  of  biliary 


44Q    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

colic,  several  small  stones  having  been  passed.  The  attacks  had 
recently  recurred  once  a  week,  and  there  had  been  a  slight  tinge 
of  jaundice  with  some  loss  of  flesh;  no  enlargement  of  the  gall- 
bladder. 

Operation. — 25/9/1902.  Cholecystotomy ;  145  gall-stones  re- 
moved. 

After -History. — Patient  made  a  good  recovery. 

Gall-stones  :  Duodeno-cholcdochotomy  and  Cholecystotomy. 

Case  456. — A  lady,  seen  with  Dr.  Maling  and  Dr.  Robinson, 
Sunderland.  Fifteen  years'  history  of  gall-stone  seizures,  with 
freedom  from  the  attacks  for  several  years ;  lately  the  attacks  had 
been  frequent.  Slight  jaundice  had  come  on  a  fortnight  ago  and 
had  gradually  deepened  ;  some  fever  and  local  peritonitis  ;  swell- 
ing of  the  gall-bladder  and  enlargement  of  the  right  lobe  of  the 
liver. 

Operation. — 30/9/1902.  Cholecystotomy;  twenty-three  gall- 
stones removed  from  the  gall-bladder,  with  a  pint  of  bile-stained 
muco-pus ;  one  stone  in  the  ampulla  of  Vater  removed  by  duo- 
deno-choledochotomy  ;  no  drainage  of  the  abdomen  ;  drainage  of 
the  gall-bladder. 

After-History. — The  patient  made  a  good  recovery,  and  is  now 
well. 

Cancer  of  Pancreas :  Cholecystenterostomy . 

Case  457. — Mrs.  B.,  aged  sixty-nine,  seen  with  Dr.  Everley 
Taylor,  Scarborough.  For  ten  months  had  suffered  from  ague- 
like attacks,  with  loss  of  flesh  and  gradually  deepening  jaundice  ; 
enlargement  of  the  liver  and  gall-bladder. 

Operation.  —  2  /  10  /  1902.  Cholecystenterostomy  ;  Murphy's 
button  used  ;  malignant  disease  of  the  head  of  the  pancreas. 

After-History.  —Patient  died  a  week  later  from  exhaustion,  due 
to  duodenal  leakage,  which  occurred  at  time  of  separation  of 
button. 

Cancer  of  Gall-bladder  and  Liver  :  Exploratory  Operation. 

Case  458. — John  W.,  aged  sixty-four,  admitted  to  the 
infirmary,  September  25,  1902.  Some  years  ago  had  attacks  of 
abdominal  pain  and  flatulence  with  jaundice.  These  attacks 
passed  off,  and  he  was  well  up  to  five  weeks  ago,  when  jaundice 
appeared  and  had  become  deeper  since.  Comparatively  little 
pain  ;  liver  and  gall-bladder  enlarged  ;  considerable  loss  of  flesh. 

Operation. — 3/10/1902.  Exploratory  laparotomy  ;  large  mass  of 
malignant  disease  found,  involving  the  gall-bladder  and  liver  ; 
secondary  growths  in  the  peritoneum. 


APPENDIX  44' 

After-History. — Good  recovery  from  operation,  and  returned 
home. 

Empyema  of  Gall-bladder,  Gall-stones  :  Cholecystotomy. 

Case  459. — Mrs.  H.,  aged  forty-eight,  seen  with  Dr.  Woodcock, 
Leeds.     (See  p.  87.) 

Cancer  of  Liver  and  Gall-bladder  :  Exploratory  Operation. 

Case  460. — Mrs.  B.,  aged  fifty-three,  seen  with  Dr.  Russell 
Coombe,  Exeter.  For  eighteen  years  the  patient  had  been  sub- 
ject to  attacks  of  biliary  colic,  but  had  never  been  jaundiced  ;  six 
months  ago  a  tumour  was  noticed  in  the  abdomen,  and  the  patient 
had  been  losing  weight  and  strength  rapidly;  there  had  been  con- 
siderable pain  ;  the  right  lobe  of  the  liver  was  enlarged,  and  the 
gall-bladder  was  distended. 

Operation. — 13/10/1902.  Exploratory  laparotomy;  carcinoma 
of  the  liver  and  gall-bladder,  incapable  of  removal. 

After -History. — Patient  recovered  from  the  operation. 

Cancer  of  Head  of  Pancreas  :  Cholecystotomy. 

Case  461. — Mr.  M.,  aged  sixty-eight,  seen  with  Dr.  Mackay, 
Knaresborough.  Eight  months'  history  of  abdominal  pain  and 
rapid  loss  of  flesh,  with  vomiting,  but  no  jaundice  ;  some  dilatation 
of  the  stomach  present. 

Operation. — 21/10/1902.  Exploratory;  carcinoma  of  the  head 
of  the  pancreas  found  ;  cholecystotomy. 

After-History. — Patient  recovered  from  the  operation,  and  lived 
for  five  months. 

Gall-stones  :  Cholecystotomy. 

Case  462. — Harriet  B.,  aged  twenty-seven,  admitted  to  the 
infirmary,  October  20,  1901.  Patient  had  suffered  from  biliary 
colic  for  twelve  months,  attacks  becoming  more  frequent,  accom- 
panied by  shivering  and  jaundice ;  enlargement  of  right  lobe  of 
liver,  with  tenderness  over  gall-bladder. 

Operation. — 23/10/1902.  Cholecystotomy ;  twenty  stones  re- 
moved. 

After-History. — Good  recovery. 

Gall-stones  :  Cholecystotomy  ;  Gastrolysis. 
Case  463.  — Miss  B.,  aged  sixty-one,  seen  with  Dr.  Brook, 
Lincoln.  Patient  had  been  subject  to  attacks  of  spasms  for  many 
years,  and  had  lately  become  an  invalid.  Slight  icteric  tinge,  but 
no  definite  jaundice,  followed  the  attacks ;  stomach  symptoms 
prominent,  and  marked  dilatation  present. 


442    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation. — 26/10/1902.  Cholecystotomy  ;  several  gall-stones 
removed  from  the  gall-bladder,  and  one  the  size  of  a  cherry  from 
the  commencement  of  the  cystic  duct ;  adhesions  between  the 
gall-bladder  and  pylorus  separated. 

After-History.—  Patient  made  a  good  recovery;  well,  July, 
1903. 

Gall-stones :  Cholecystotomy. 

Case  464. — Emma  F.,  aged  thirty-one,  admitted  to  the  infir- 
mary, October  24,  1902.  For  three  years  had  had  attacks  of 
biliary  colic,  last  attack  followed  by  jaundice ;  tenderness  on 
deep  pressure  in  mid-line,  i^-  inches  above  the  umbilicus. 

Operation. — 30/ 1  o  1 902 .  Cholecystotomy ;  one  large  and  several 
small  gall-stones  removed  from  the  gall-bladder. 

After-History. — Good  recovery. 

Cancer  of  Pancreas,  Ascites  :  Exploratory  Operation. 

Case  465. — Mary  T.,  aged  fifty-one,  admitted  to  the  infirmary, 
October  29,  1902.  Painless  onset  of  jaundice  a  year  ago  ;  rapid 
loss  of  flesh  lately ;  enlargement  of  the  liver ;  no  tenderness  or 
enlargement  of  gall-bladder. 

Operation.  —  30/10/1902.  Exploratory  operation;  mass  of 
enlarged  glands  in  hepatic  fissure  ;  enlargement  of  liver  ;  ascites  ; 
growth  in  head  of  pancreas. 

After -History. — Recovery  from  operation. 

Gall-stones  in  Common  Duct,  A  hsence  of  Jaundice  :  Choledochotomy  ; 

Cholecystotomy. 

Case  466. — Miss  H.,  aged  fifty-seven,  seen  with  Dr.  Garrad, 
Starbeck.  Patient  had  suffered  from  epigastric  pain  for  five 
years;  the  attacks  were  very  acute,  and  accompanied  by  vomiting. 
No  haematemesis  or  jaundice  ;  there  had  been  some  loss  of  flesh  ; 
no  enlargement  of  the  gall-bladder,  but  considerable  tenderness. 

Operation. — 4/11/1902.  Cholecystotomy;  several  gall-stones 
removed  from  the  gall-bladder  ;  one  stone  firmly  impacted  in  the 
common  duct  removed  by  choledochotomy.  It  is  noteworthy 
that  in  this  case,  although  there  was  a  stone  in  the  common  duct, 
there  was  no  jaundice. 

After-History. — Patient  made  a  good  recovery  ;  well,  June,  1903. 

Gall-stones  :  Cholecystotomy. 

Case  467. — Miss  H.,  aged  thirty-eight,  seen  with  Dr.  Squance, 
Sunderland.  Attacks  of  biliary  colic  for  many  years  ;  patient  had 
never  been  jaundiced,  but  lately  the  attacks  had  become  more 
frequent,  and  there  had  been  loss  of  flesh  and  strength.  The  gall- 
bladder was  enlarged,  distended,  and  very  tender. 


APPENDIX  443 

Operation. — 10/11/1902.  Cholecystotomy  ;  several  gall-stones 
removed  from  the  gall-bladder  and  cystic  duct. 

After-History. — Patient  made  a  good  recovery,  and  remains  well. 

Chronic  Pancreatitis ;  Hourglass  Gall-bladder  :  Partial  Cholecystectomy  ; 

Cholecystotomy. 

Case  468. — Fred  B.,  aged  fifty-eight,  seen  at  the  infirmary. 
For  years  had  been  subject  to  attacks  of  biliary  colic,  and  ten 
years  before  had  had  jaundice,  which  passed  off.  Two  months 
previous  to  admission  had  severe  pain,  followed  by  jaundice.  He 
had  had  three  rigors  since,  and  the  jaundice  had  persisted.  Xo 
distension  of  the  gall-bladder.    Pancreatic  crystals  found  in  urine. 

Operation.  —  2 1/11/ 1902.  Partial  cholecystectomy  and  chole- 
cystotomy ;  hourglass  gall-bladder ;  no  calculi  discovered,  but 
hardening  of  the  head  of  the  pancreas  felt  (chronic  pancreatitis). 
The  distal  portion  of  the  gall-bladder  was  removed,  and  a  tube 
inserted  into  the  proximal  end. 

After-History. — Patient  recovered  from  the  operation,  and 
improved  very  markedly.  He  gained  flesh  and  strength,  but 
whenever  the  fistula  closed  he  became  jaundiced,  though  the 
small  sinus  only  discharged  a  little  bile,  even  with  a  tube  inserted. 
For  further  history,  see  Case  538. 

Cholecystitis  :  Cholecystectomy. 

Case  469. — Michael  C.,aged  thirty-eight,  seen  at  the  infirmary. 
For  twelve  months  had  been  subject  to  attacks  of  biliary  colic  ; 
during  the  last  attack  the  patient  was  jaundiced  ;  no  enlargement 
of  the  gall-bladder. 

Operation. — 25/11/ 1902.  Cholecystectomy;  gall-bladder  small, 
contracted,  and  adherent  to  pylorus  and  bowel ;  no  gall-stones 
found ;  gall-bladder  removed. 

After-History. — Patient  made  a  good  recovery. 

Cancer  of  Liver  :  Exploratory  Operation. 

Case  470. — Mrs.  P.,  aged  sixty,  seen  with  Dr.  Hutchinson, 
Bridlington.  Failure  of  health  for  one  year;  gradual  enlarge- 
ment of  the  abdomen,  rapid  loss  of  flesh.  No  jaundice,  but  liver 
greatly  enlarged. 

Operation.  —  25/11/ 1902.  Exploratory;  primary  malignant 
disease  of  the  liver,  with  pedunculated  right  lobe ;  gall-bladder 
small ;  nodules  on  surface  of  liver. 

After- History. —  Patient  recovered  from  the  operation,  and  lived 
until  May,  1903. 


444    DISEASES  OE  THE  GALL-BLADDER  AND  BILE-DUCTS 

Gall-stones :  Cholecystotomy. 

Case  471.— Mrs.  W.,  aged  fifty-nine,  seen  with  Dr.  Dobie, 
Keighley.  Had  suffered  from  painful  attacks  of  indigestion  for 
some  years ;  lately  after  an  attack  of  pain  there  had  been  slight 
jaundice,  with  some  swelling  and  tenderness  of  the  gall-bladder. 
No  ague-like  attacks ;  no  serious  loss  of  flesh ;  slight  jaundice 
present. 

Operation. — 26/11/1902.  Cholecystotomy;  gall-bladder  full  of 
mucus  and  walls  acutely  inflamed  ;  two  gall-stones  removed  about 
the  size  of  walnuts,  one  impacted  in  the  cystic  duct ;  several  other 
small  stones  removed  at  the  same  time. 

After-History. — Patient  made  a  good  recovery. 

Gall-stones :  Cholecystotomy. 

Case  472. — Mrs.  R.,  aged  fifty-nine,  seen  in  London  with 
Dr.  Huxley  and  Dr.  Armstead,  suffering  from  repeated  attacks 
of  biliary  colic,  associated  with  very  slight  jaundice  and  marked 
tenderness  over  the  gall-bladder. 

Operation. — 1/1 2/1902.  Cholecystotomy  ;  numerous  gall-stones 
removed  from  the  gall-bladder  and  cystic  duct. 

After-History. — Good  recovery;  well,  June,  1903. 

Gall-stone :  Cholecystotomy. 

Case  473.— Mr.  T.,  aged  thirty,  seen  with  Dr.  Wylie,  Salis- 
bury. Three  years  ago  had  an  attack  of  biliary  colic,  but  was 
quite  well,  'with  the  exception  of  one  other  attack,'  up  to  three 
months  ago.  Since  then  he  had  had  numerous  attacks,  and 
though  there  had  been  no  manifest  jaundice,  there  was  an  icteric 
tinge  of  the  conjunctiva.     No  enlargement  of  the  gall-bladder. 

Operation. — 4/12/1902.  Cholecystotomy;  one  gall-stone  impacted 
in  the  cystic  duct  removed  by  scoop  through  cholecystotomy 
incision. 

After- History. — Patient  made  a  good  recovery,  and  is  now  quite 
well. 

Gall-stones  :  Cholecystotomy. 

Case  474. — Mrs.  S.,aged  sixty-three,  seen  with  Dr.  Lockwood, 
Halifax.  For  about  six  years  had  suffered  from  spasms  and 
acute  indigestion,  but  for  fifteen  months  the  attacks  had  been 
more  severe,  and  localized  in  the  right  hypochondriac  region. 
There  had  occasionally  been  slight  jaundice  after  the  attacks ;  no 
loss  of  flesh,  but  the  patient  had  become  weak  and  unable  to  carry 
out  her  home  duties. 

Operation.  — 17/12/1902.  Cholecystotomy;  198  gall-stones 
removed  from  the  gall-bladder  and  cystic  duct. 

After-History. — Patient  made  a  good  recovery. 


APPENDIX  445 

Cancer  of  Pancreas  :  Cholecystotomy. 

Case  475. — Mr.  W.,  aged  fifty-five,  seen  with  Dr.  Claremont, 
Southsea.  Never  had  attacks  of  biliary  colic,  but  had  been 
subject  to  dyspepsia  ;  six  months  ago  had  a  rigor,  followed  by 
jaundice ;  had  had  repeated  rigors  since,  but  without  pain  of  any 
kind;  vomiting  at  times,  with  marked  loss  of  flesh;  some  enlarge- 
ment of  the  liver  and  gall-bladder ;  had  lost  2  stones  in  weight  ; 
bulky,  fatty,  pale  motions  ;  coarse  pancreatic  crystals  in  urine. 

Operation.  —  2/1/1903.  Cholecystotomy;  enlargement  of  the 
head  of  the  pancreas,  probably  malignant ;  gall-bladder  distended. 

After -History. — Recovery.  Two  months  later  the  patient  was 
gradually  losing  ground.  All  the  bile  was  draining  through  the 
fistula.  There  was  no  jaundice,  and  he  was  free  from  pain. 
Lived  for  eight  months. 

Gall-stones,  Jaundice,  and  Infective  Cholangitis  :  Choledochotomy. 

Case  476. — Maria  B.,  aged  sixty-two,  seen  at  the  Leeds 
General  Infirmary.  Fourteen  years'  history  of  biliary  colic,  but 
for  six  months  the  attacks  had  become  frequent  and  were  followed 
by  jaundice,  which  usually  persisted  for  four  or  five  days.  The 
attacks  were  associated  with  rigors,  and  the  patient  became 
enfeebled  and  very  ill.  Some  enlargement  of  the  right  lobe  of 
the  liver  noticed  on  admission,  but  no  distension  of  the  gall- 
bladder and  no  jaundice. 

Operation. — 7/1/1903.  Cholecystotomy  and  choledochotomy; 
one  stone  removed  from  the  common  duct,  and  several  from  the 
gall-bladder ;  duct  sutured  ;  gall-bladder  drained. 

After-History. — Patient  made  a  good  recovery,  and  was  well  in 
April,  1903. 

Gall-stones :  Cholecystotomy. 

Case  477. — Mr.  M.,  aged  sixty-four,  seen  with  Dr.  Newby, 
Grimsby.  Fifteen  years  ago  the  patient  used  to  have  attacks  of 
spasms,  but  was  never  jaundiced.  He  was  free  up  to  two  years 
ago,  when  he  had  a  typical  attack  of  biliary  colic,  lasting  for  eight 
hours.  Had  had  several  attacks  since,  and  had  been  slightly 
jaundiced.  No  enlargement  of  the  gall-bladder,  but  tenderness 
above  the  umbilicus. 

Operation. — 8/1/1903.  Cholecystotomy;  small  and  contracted 
gall-bladder  filled  with  calculi ;  extensive  adhesions  separated. 

After-History.  —  Patient  made  a  good  recovery,  and  remains  well. 

Chronic  Pancreatitis  :  Cholecystotomy  ;  Gastrolysis. 

Case  478. — Mrs.  B.,  aged  forty-four,  seen  with  Dr.  Lovely, 
Dawlish.      Eighteen  years  ago  both   ovaries  were  removed  by 


446    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Sir  Spencer  Wells.  About  a  year  ago  the  patient  began  to  suffer 
from  abdominal  pain  and  diarrhoea.  The  diarrhoea  persisted, 
the  motions  containing  quantities  of  undigested  food.  The  attacks 
of  pain  had  also  been  frequent,  and  morphia  had  been  required. 
The  pain  had  always  been  localized — 2  inches  above  the  umbilicus 
and  2  inches  to  the  right  of  the  middle  line — and  when  it  was  acute 
it  passed  through  to  the  back.  There  had  never  been  any  vomiting 
or  nausea.  Up  to  the  last  week  there  had  been  no  jaundice ;  no 
loss  of  flesh  ;  urine  gave  pancreatitic  reaction. 

Operation. — 11/1/1903.  Cholecystotomy  ;  adhesions  about  the 
pylorus  and  gall-bladder  detached  and  pancreatitic  swelling  felt. 

A ftcv -History. — Patient  made  a  good  recovery  from  the  opera- 
tion, and  remained  comparatively  well  for  three  months,  when, 
after  an  attack  of  appendicitis,  which  had  evidently  been  present 
before  in  a  chronic  form,  appendicectomy  and  nephropexy  were 
performed.  Good  recovery  from  the  second  operation ;  urine  then 
gave  no  pancreatitic  reaction.  When  the  abdomen  was  opened 
for  appendicectomy  the  pancreas  was  felt  to  be  normal  in  size. 

Septicemia  of  Doubtful  Origin,  apparently  from  Infected  Bile-ducts  : 

Cholecystotomy. 

Case  479. — Mr.  B.,  aged  forty-eight,  seen  with  Dr.  Mitchell 
Bruce,  Dr.  Marshall,  and  Dr.  Mackintosh.  Since  an  illness 
associated  with  fever  and  called  influenza  four  months  previously 
had  never  been  well  enough  to  get  out,  and  barely  able  to  get  up. 
Intermittent  feverish  attacks  associated  with  rigors,  great  depres- 
sion, and  loss  of  flesh,  but  without  pain,  culminated  in  continuous 
fever,  with  exacerbations,  associated  with  enlargement  of  the 
liver  and  gall-bladder,  with  some  tenderness  there.  It  was  thought 
that  there  might  be  suppurative  cholangitis,  which  might  be 
relieved  by  drainage.  Nothing  else  definitely  to  be  made  out, 
except  soft  mitral  cardiac  bruit  and  some  laryngeal  catarrh. 

Operation. — 12/1/ 1903.  Cholecystotomy  performed,  and  a 
quantity  of  bile  evacuated  from  the  gall-bladder,  apparently  giving 
immediate  relief.  The  wound  healed  by  first  intention,  but  as 
soon  as  the  drainage  of  bile  ceased,  at  the  end  of  a  fortnight,  the 
fever  returned,  and  with  it  all  the  previous  symptoms,  which 
within  a  few  weeks  led  to  a  fatal  termination.  The  bile  was  free 
from  pus,  but  contained  bacilli  actively  growing  aerobically  and 
anaerobically  in  all  kinds  of  media.  Mr.  Kastes  said  that  he  was 
unable  to  identify  them  with  any  previously  described,  but  culti- 
vations made  by  Dr.  Eyre,  bacteriologist  to  Guy's  Hospital,  and 
injected  into  guinea-pigs  and  rabbits,  produced  no  ill  effects. 
The  pancreas  was  mucli  swollen,  but  no  fluctuation  could  be  felt. 


A  PPENDIX  447 

Gall-stones  in  Common  Duct,  Cholecystitis  :  Cholecystectomy  and 
Dnodeno-choledochotomy . 

Case  480. — Mrs.  K.,  aged  fifty-nine,  seen  with  Dr.  Rolleston 
and  Dr.  Swan,  London.  History  of  gall-stones  for  two  or  three 
years,  and  of  jaundice  with  ague-like  attacks  for  nine  months, 
with  great  loss  of  flesh  during  the  latter  period  ;  right  lobe  of  the 
liver  markedly  enlarged  ;  no  distension  of  the  gall-bladder  ;  tender- 
ness above  and  to  the  right  of  the  umbilicus. 

Operation. — 17/1/1903.  Small,  shrunken  gall-biadder  removed 
by  cholecystectomy  ;  very  firm  adhesions  between  the  pylorus, 
duodenum,  gall-bladder,  and  liver,  detached.  During  the  manipu- 
lations one  gall-stone  was  forced  into  the  ampulla  of  Vater,  and 
thence  into  the  duodenum,  whence  it  was  extracted  by  duodeno- 
choledochotomy. 

After-History. — Patient  made  a  good  recovery,  and  left  the 
surgical  home  at  the  month  end  ;  quite  well,  July,  1903. 

Gall-stones  in  Common  Duct,  Pancreatitis  :  Choledochotomy. 
Case  481. — Mrs.  P.,  aged  sixty-one,  seen  with  Dr.  Pemberton, 
Burnley.     (See  p.   128.) 

Gall-stones  :  Cholecystotomy. 

Case  482. — Mrs.  A.,  aged  fifty-two,  seen  with  Dr.  Applegate, 
Dewsbury.  Patient  had  had  spasms  for  years,  but  had  never 
been  jaundiced  ;  two  years  ago  had  a  severe  attack  of  pain,  and 
bile  appeared  in  the  urine  ;  lately  had  had  other  severe  attacks, 
followed  by  jaundice  ;  there  had  been  great  loss  of  flesh.  When 
seen  there  wTas  some  slight  dilatation  of  the  stomach,  and  the  right 
lobe  of  the  liver  was  somewhat  enlarged,  but  no  distension  of  the 
gall-bladder  could  be  made  out ;  there  was  decided  tenderness  just 
above  and  to  the  right  of  the  umbilicus. 

Operation. — 22/1/1903.  Cholecystotomy ;  six  large  and  in- 
numerable small  stones  removed  from  the  gall-bladder  and  cystic 
duct. 

Aftev-History. — Patient  made  a  good  recovery  ;  well,  July,  1903. 

Gall-stones  in  Common  Duct,  Infective  Cholangitis :  Choledochotomy ; 
Cholecystectomy ;  Entevovrhaphy. 

Case  483.—  Mr.  I.,  aged  fifty,  seen  with  Dr.  Brown,  Taunton. 
(Seep.   114.) 

Suppurative  Cholangitis,  Dilated  Common  Duct,  Cancer  of  Pancreas  : 

Cholcdochostomy. 

Case  484. — Mr.  R.,  aged  seventy-five,  seen  with  Dr.  Curd  and 

Dr.  Cooke,  Bath.     Patient  was  fairly  well  up  to  a  fortnight  ago, 

when  he  was  seized  with  a  severe  pain  at  the  epigastrium,  which 

caused  him  to  faint.     The  next  day  jaundice  appeared,  and  became 


448    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

intense.  A  week  ago  he  had  fever,  with  temperature,  which  had 
since  been  high,  on  one  occasion  1050  F.  There  was  no  tenderness 
or  rigidity  of  the  recti ;  slight  enlargement  of  the  liver  ;  some 
hemorrhagic  areas  in  the  skin  ;  pulse  very  feeble.  On  further 
questioning  it  was  found  that  the  patient  had  had  three  previous 
attacks  of  abdominal  pain,  but  without  jaundice.  Coarse  pan- 
creatic crystals  in  urine  suggestive  of  cancer. 

Operation. — 30/1/ 1903.  Choledochostomy  ;  extensive  adhesions  ; 
gall-bladder  small  and  shrunken  ;  cystic  and  common  ducts 
dilated  to  the  size  of  the  small  intestine  ;  the  ducts  were  aspirated, 
and  8  ounces  of  cloudy,  purulent  bile  removed  ;  no  gall-stones 
found  ;  tube  sutured  into  an  opening  in  the  common  duct  ;  hard- 
ness felt  in  head  of  pancreas. 

After-History. — Patient    died    fourteen    days    later    from    ex- 
haustion. 
Cancer  of  Gall-bladder  and  Liver  :  Cholecystectomy  and  Hepatectoiuy. 

Case  485. — Mr.  B.,  aged  fifty-five,  seen  in  London  with  Dr. 
Berry.  Thirty-seven  years  ago  patient  had  had  catarrhal  jaundice, 
lasting  a  week  or  two,  and  had  suffered  from  attacks  of  epigastric 
pain,  said  to  be  indigestion  ;  at  forty-four  had  had  an  attack  of  pain 
followed  by  jaundice,  which  lasted  a  month,  and  then  had  a  dull, 
aching  pain  in  the  epigastrium  ;  latterly  the  pain  had  become 
more  severe,  and  he  had  lost  weight  ;  there  was  a  nodular  tumour 
below  the  liver,  apparently  the  gall-bladder  ;  no  ascites. 

Operation. — 5/2/1903.  Cancer  of  the  gall-bladder,  which  also 
contained  gall-stones  ;  nodule  of  growth  in  the  liver  from  exten- 
sion ;  cholecystectomy  and  partial  hepatectomy  ;  elastic  ligature 
and  hysterectomy  pins  employed. 

After-History. — Patient  recovered  from  the  operation,  and  moved 
to  the  seaside,  where  he  succumbed  four  months  later  to  secondary 
growths  in  the  abdomen. 

Cancer  of  Pancreas  :  Cholccystenterostomy . 

Case  4*6. — Mr.  A.,  aged  fifty-three.  Two  years  ago  had  a 
severe  attack  of  pain  in  the  right  hypochondrium  ;  six  months 
later  had  another  attack,  which  was  more  severe  and  was  followed 
by  jaundice  which  lasted  for  six  weeks  ;  patient  was  very  ill  and 
lost  weight  rapidly  ;  cholecystotomy  was  performed  in  January, 
1 90 1,  by  another  surgeon.  He  was  said  to  have  had  chronic 
pancreatitis  at  that  time.  A  biliary  fistula  had  persisted,  though 
bile  had  been  present  in  the  motions  off  and  on  since  the  opera- 
tion ;  he  had  had  no  pain  since  the  operation,  but  on  several 
occasions  had  had  rigors,  and  on  one  occasion  a  temperature  reach- 
ing to  1050  F.;  steady  loss  of  weight ;  once,  when  the  fistula  closed 
for  four  days,  jaundice  returned.  Coarse  pancreatic  crystals  found 
in  urine. 


APPENDIX  449 

Operation. — 5/2/1903.  Cancer  of  the  pancreas,  which  had  pro- 
bably started  in  the  ampulla  of  Vater  ;  cholecystenterostomy 
performed. 

After-History. — Though  the  wound  healed  almost  completely, 
the  strength  was  not  regained,  and  the  patient  died  five  weeks 
later  from  exhaustion.  The  Murphy's  button  employed  for  the 
anastomosis  was  passed  on  the  tenth  day. 

Cholelithiasis  and  Pancreatic  Calculi :  Cholccystotomy ;  Duodeno- 
choledochotomy ;  Pancreatotomy. 

Case  487. — Mrs.  W.,  aged  fifty-seven,  seen,  February  1,  1903, 
with  Sir  Richard  Douglas  Powell.  In  August,  1901,  the  patient 
had  several  attacks  of  biliary  colic,  unaccompanied  by  jaundice  ; 
was  seen  by  Sir  Douglas  Powell  on  August  24,  and  cholangitis 
diagnosed  ;  since  that  time  she  had  had  frequent  recurrences  of 
pain,  which  she  had  called  indigestion.  In  May,  1902,  a  serious 
attack  occurred,  requiring  opiates  for  relief ;  this  was  followed  by 
two  or  three  severe  seizures,  after  which  she  was  better  for  a  time. 
At  Christmas,  1902,  the  attacks  of  pain  became  more  frequent, 
and  in  the  first  week  of  January,  1902,  she  had  to  take  to  her  bed. 
Vomiting  occurred  rather  frequently,  so  that  she  was  unable  to 
take  any  food  beyond  a  little  milk.  When  I  saw  her  with  Sir 
Richard  Douglas  Powell,  her  pulse  was  120,  and  feeble.  There 
had  been  a  moderate  increase  of  temperature  for  several  days  ; 
slight  jaundice  was  present,  but  no  enlargement  of  the  gall-bladder 
could  be  felt.  The  region  of  the  gall-bladder  was,  however, 
decidedly  tender,  and  there  was  a  well-marked  area  of  tenderness 
on  the  left  of  the  spine.  She  was  vomiting  everything,  and  was 
in  such  a  poor  condition  that,  although  operation  was  indicated,  it 
seemed  improbable  that  she  would  be  able  to  bear  it.  It  was 
therefore  decided  to  feed  her  by  the  bowel,  and  to  stop  all  food  by 
the  mouth,  to  give  strychnia  subcutaneously  and  calcium  chloride 
by  the  bowel,  so  as  to  try  to  get  her  into  a  little  better  condition. 
After  ten  days  of  this  treatment  she  had  improved  so  much  that 
operation  was  decided  on.  A  specimen  of  the  urine  sent  to  Mr. 
Cammidge  was  reported  by  him  to  contain  pancreatic  crystals, 
indicating  pancreatitis. 

Operation. — 13/2/ 1903.  A  contracted  gall-bladder  was  found, 
and  seven  gall-stones,  together  with  mucus  and  pus,  were  removed 
from  the  cystic  duct.  The  common  duct  was  slightly  dilated,  and 
there  was  a  decided  hardness  about  the  head  of  the  pancreas. 
A  hard  nodule  could  be  felt  in  the  pancreas  near  to  the  common 
duct.  This  was  cut  down  on,  and  found  to  be  a  white  pancreatic 
stone  about  the  size  of  a  pea.  It  was  removed  and  the  pancreas 
sutured  over  it.     The  ampulla  of  Vater  was  then  exposed  by  an 

29 


450    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

incision  in  the  duodenum,  the  papilla  being  laid  open  over  a 
director,  and  from  the  pancreatic  duct  another  white  calculus  of 
the  same  size  was  extracted  by  forceps,  after  which  a  probe  could 
be  passed  for  il  inches  along  the  pancreatic  duct.  At  the  same 
time  the  common  bile-duct  was  explored  and  found  to  be  free. 
An  explanation  was  now  sought  for  the  pain  which  had  been  felt 
on  the  left  side  of  the  spine,  and  on  pressing  the  finger  through 
the  lesser  omentum  a  hard  lump  was  felt  about  the  centre  of  the 
pancreas,  it  being  clearly  a  pancreatic  calculus.  The  gastro- 
hepatic  omentum  was  divided  so  as  to  give  access  to  the  lesser 
cavity  of  the  peritoneum.  An  incision  was  then  made  through  the 
pancreas  into  the  main  pancreatic  duct,  from  which  a  calculus, 
the  size  of  a  cob-nut,  was  extracted  by  a  scoop,  it  being  firmly 
adherent  to  the  duct.  A  large  vessel  was  wounded,  probably  a 
branch  of  the  portal  vein,  but  this  was  secured  by  ligature.  The 
pancreatic  duct  was  sutured,  and  the  pancreatic  substance  was 
brought  together  by  two  layers  of  catgut  sutures.  The  slit  in  the 
gastro-hepatic  omentum  was  sutured  ;  the  gall-bladder  was  drained, 
and  a  small  split-drain  passed  down  into  the  region  of  the  incision 
in  the  duodenum,  the  rest  of  the  wound  being  closed. 

After -History.  — The  patient  made  a  steady  though  slow  recovery, 
and  on  April  30  I  had  a  letter  to  say  that  the  wound  had  healed 
completely  at  the  end  of  seven  weeks,  and  that  the  patient  was 
able  to  be  in  the  drawing-room.  Twelve  weeks  after  the  opera- 
tion she  had  an  attack  of  pain  associated  with  a  temperature,  this 
being  repeated  on  one  or  two  subsequent  occasions,  though 
nothing  was  discovered  to  account  for  it.  On  July  27  I  had  a 
letter  to  say  :  '  I  am  pleased  to  be  able  to  give  you  a  good  report 
of  your  patient.  From  June  2  up  to  the  present  time  there  has 
been  steady  improvement,  and  the  patient  has  been  able  to  resume 
her  household  duties  and  to  go  out  for  drives.'  November,  1903, 
said  to  be  quite  well. 

Gall-stones,  Gastric  Ulcer  :  Cholecystotomy  ;  Excision  of  Ulcer  ; 

G astro -enterostomy. 

Case  488. — Mr.  S.,  aged  fifty-five,  seen  with  Dr.  McGregor 
Young,  Leeds.     (See  p.  259.) 

Gall-stones ;  Cholecystotomy. 

Case  489. — Mr.  W.,  aged  forty-five,  seen  with  Dr.  Robinson, 
Sunderland.  For  some  years  subject  to  severe  attacks  of  biliary 
colic.  No  enlargement  of  the  gall-bladder,  but  tenderness  above 
and  to  the  right  of  the  umbilicus ;  no  permanent  jaundice. 

Operation.  —  26/2/1903.     Cholecystotomy;    one  large  stone  and 


APPENDIX  451 

several  small  ones  removed  from  the  gall-bladder  and  cystic  duct; 
drainage. 

After-History.     Patient  made  a  good  recovery,  and  is  now  well. 

Cancer  of  Liver  and  Pancreas  :  Cholccystotomy. 

Case  490. — Mr.  H.,  aged  forty-three,  seen  with  Dr.  Hosking, 
Turner's  Hill.  Twenty  years  ago  the  patient  had  typhoid  fever. 
For  six  months  had  had  attacks  of  abdominal  pain,  and  in 
January  jaundice  appeared,  and  had  persisted  since.  He  had 
lost  flesh  lately,  and  was  very  ill  and  feeble.  There  was  some 
enlargement  of  the  right  lobe  of  the  liver,  and  distension  of  the 
gall-bladder,  but  no  marked  tenderness. 

Operation. — 5/3/1903.  Cholecystotomy  performed  to  relieve  the 
jaundice  due  to  cancer  of  the  pancreas  and  liver. 

After-History. — Patient  recovered  from  the  operation,  and  lived 
for  two  months. 

Gall-stones  and  Pyloric  Stenosis  :  Cholecystotomy  and  Gastro- 
enterostomy. 

Case  491. — Rebecca  S.,  aged  fifty,  seen  at  the  Leeds  General 
Infirmary.  Six  months'  history  of  attacks  of  pain  and  jaundice, 
and  loss  of  flesh.  Vomiting  had  been  frequent,  and  at  times 
large  quantities  were  ejected.  Patient  was  very  ill  and  emaciated, 
and,  besides  a  tumour  in  the  hypochondrium,  she  had  great  dilata- 
tion of  the  stomach. 

Operation. — 9/3/1903.  Gastroenterostomy  for  pyloric  stenosis, 
and  cholecystotomy  for  removal  of  a  large  number  of  gall-stones. 

After-History. — Patient  recovered  from  the  operation,  and  left 
the  infirmary.  Five  weeks  later  she  had  an  illness,  said  to  be 
acute  pneumonia,  of  which  she  died. 

Post-mortem. — Empyema  of  the  left  pleura  was  found,  with  an 
abscess  in  the  lung.  The  gastro-enterostomy  was  perfect,  and 
the  abdominal  wound  was  soundly  healed.  The  ducts  and  gall- 
bladder were  clear  of  stones  and  healthy. 

Gall-stones  in  Hepatic  and  Common  Ducts,  Chronic  Pancreatitis  : 

Choledochotomy. 
Case  492. — Mrs.  D.,  aged  fifty-nine,  seen  with  Dr.  Lawrie, 
Kilmarnock.  Twenty-six  years  ago  patient  began  to  suffer  from 
abdominal  pain,  followed  by  jaundice  and  vomiting  ;  subject  to 
attacks  at  longer  or  shorter  intervals  ever  since.  Fifteen  years 
ago  was  in  bed  for  three  months,  with  constant  pain.  Never  had 
rigors.  A  fortnight  ago  had  a  severe  attack  of  pain,  followed  by 
jaundice,  which  persisted.  Had  lost  4  stones  in  weight.  Xo 
enlargement  of  the  liver  or  gall-bladder  ;  some  dilatation  of  the 
stomach.    Pancreatic  crystals  found  in  urine. 

29 — 2 


452    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation. — 10/3/1903.  Cholecystotomy  ;  small  gall-bladder, 
containing  two  stones,  which  were  removed,  and  the  gall-bladder 
drained.  Common  and  hepatic  ducts  contained  many  stones,  which 
were  removed  through  an  incision  in  the  common  duct ;  chole- 
dochotomy,  with  suture  of  the  duct.     Slightly  swollen  pancreas. 

After-History. — Patient  made  a  good  recovery,  and  remains  well. 

Cancer  of  Gall-bladder  and  Liver  :  Exploration. 

Case  493. — Mrs.  M.,  seen  with  Dr.  Hodgson,  Burnley.  For 
six  months  had  been  suffering  from  painful  indigestion,  and  during 
the  last  month  had  been  losing  flesh.  Six  weeks  ago  had  a  severe 
attack  of  abdominal  pain,  followed  by  jaundice  ;  the  pain  had  been 
constant  since,  and  the  jaundice  had  persisted  and  deepened. 
There  had  been  slight  shivering  attacks  on  several  occasions. 
Tenderness  over  the  gall-bladder  region  elicited,  with  some  swell- 
ing of  the  right  border  of  the  liver,  feeling  like  a  hard,  nodular 
tumour. 

Operation.  —  1 0/3/1903.  Exploratory  laparotomy  ;  cancer  of  the 
gall-bladder,  with  cancer  of  the  adjoining  portion  of  the  right  lobe 
of  the  liver.     Secondary  growths  felt  in  the  portal  fissure. 

After- History. — Recovered  from  operation  and  returned  home  in 
three  weeks. 

Deep  Jaundice,  Acute  Cirrhosis  of  Liver  :  Exploration  of  Pancreas 
through  Duodenum  ;  Drainage. 

Case  494. — Georgina  W.,  aged  twenty-three,  seen  at  the  Leeds 
General  Infirmary.  Jaundice  was  first  noticed  eight  months  ago, 
and  had  persisted  since  with  varying  intensity.  There  had  been 
no  attacks  of  pain,  but  the  patient  had  been  extremely  ill  and 
feeble.  She  had  occasionally  been  sick,  and  for  the  last  fortnight 
had  vomited  almost  every  day  directly  after  food.  There  had 
been  no  pain  throughout.  Patient  extremely  ill,  and  so  feeble 
that  operation  was  only  done  at  the  urgent  request  of  the  patient 
and  her  friends.  Examination  negative,  except  for  some  enlarge- 
ment of  the  liver  and  spleen. 

Operation. — 17/3/1903.  Exploratory  operation;  gall-bladder 
distended  with  bile,  aspirated,  opened,  and  drained.  No  stones 
found  ;  tube  stitched  in.  The  ampulla  of  Vater  was  explored 
through  an  incision  in  the  duodenum,  as  it  was  thought  that 
something  hard  was  obstructing  the  pancreatic  duct,  but  nothing 
abnormal  was  found,  except  slight  hardening  of  the  pancreas. 
The  opening  in  the  duodenum  was  closed  by  sutures.  The  liver 
looked  black  and  congested. 

After-hlistory. — During  the  night  following  operation  the  patient 
became  collapsed  and  blanched.     Haemorrhage  took  place  from 


APPENDIX  453 

the  tube  in  the  gall-bladder,  and  from  the  stitch  punctures.     She 
gradually  became  weaker,  and  died  the  next  day. 

Post  mortem. — Haemorrhages  found  in  the  substances  of  the  lungs, 
and  about  the  root  of  the  left  lung.  About  2  ounces  of  blood  found 
in  the  peritoneal  cavity.  The  spleen  was  slightly  enlarged,  the 
pancreas  normal,  (?)  except  for  small  areas  of  necrosis,  probably 
post-mortem  digestion.  The  liver  showed  bright  yellow  nodules 
on  the  surface  and  on  section.  Microscopically,  there  was  active 
cirrhosis,  with  formation  of  much  connective  tissue.  The  nodules 
were  areas  where  the  liver  cells  had  undergone  necrosis.  One 
pathologist  suggested  the  condition  was  acute  atrophy  of  the  liver, 
another  acute  cirrhosis  with  pancreatitis. 

Cholecystitis,  Residual  Abscess,  Chronic  Pancreatitis  :  Cholecystectomy. 

Case  495. — Mr.  O.,  aged  fifty-nine,  seen  with  Dr.  Le  Rosignol, 
Jersey.  A  year  ago  had  an  attack  of  biliary  colic,  followed  by 
numerous  attacks  since,  the  last  two  having  been  followed  by 
jaundice.  The  liver  was  somewhat  enlarged,  and  there  was  tender- 
ness to  the  right  of,  and  above,  the  umbilicus.  No  enlargement 
of  the  gall-bladder. 

Operation.  —26/3/1903.  Extensive  adhesions  ;  swelling  of  head 
of  pancreas ;  remnant  of  abscess  between  the  gall-bladder  and 
duodenum  found,  but  no  gall-stones  ;  gall-bladder  thickened  and 
contracted  ;  cholecystectomy  ;  drainage  of  the  cystic  duct. 

After-History. — Patient  made  a  good  recovery,  and  wTas  able  to 
return  home  in  the  fifth  week. 

Gall-stones  :  Cholecystotomy. 

Case  496. — John  W.  H.,  aged  thirty-five,  seen  at  the  Leeds 
Infirmary.  Six  months'  history  of  attacks  of  biliary  colic,  with 
occasional  jaundice  ;  no  rigors  ;  tenderness  over  the  gall-bladder, 
but  no  tumour. 

Operation. — 31/3/1903.  Cholecystotomy;  a  number  of  small 
stones  removed. 

After-History.  —  Patient  made  a  good  recovery,  and  continues 
well. 

Cancer  of  the  Pancreas,  Jaundice,  Ascites  :  Cholecystotomy. 

Case  497. — Dr.  S.,  aged  sixty-two,  seen  with  Dr.  Mason, 
Walton-on-Thames.  Patient  had  been  failing  in  health  for  three 
years,  and  had  become  anaemic  through  rectal  haemorrhage  from 
piles.  Six  months  previously  he  had  a  rigor,  followed  by  jaundice, 
which  persisted  for  six  weeks,  and  then  passed  off.  Two  months 
previously  the  jaundice  recurred  without  pain,  and  had  persisted, 
it   being  associated  with   anorexia    and   great   loss  of   flesh  and 


454    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

strength.  There  was  an  enlarged  liver  with  a  distended  gall- 
bladder, but  no  tenderness  over  either.  Slight  ascites  detected, 
and  there  was  some  oedema  of  the  feet.  Cancer  of  the  pancreas 
diagnosed,  but  patient  wishful  to  have  an  exploratory  operation 
on  the  chance  of  getting  even  temporary  relief. 

Operation. — 4/4/1903.  Cholecystotomy  ;  cancer  of  the  head  of 
the  pancreas  and  ascites. 

Aftev-History. — The  operation  was  well  borne.  A  few  hours 
later  the  patient  had  an  attack  of  syncope,  from  which  he  rallied, 
but  died  twenty-four  hours  later  from  cardiac  failure. 

Gall-stone  in  Hepatic  Duct :  Choledochotomy  and  Cholecystotomy. 

Case  498. — Mrs.  F.,  aged  sixty-two,  seen  with  Dr.  Rayner, 
Stockport.     Operation,  April  15,  1903.     Well,  December,  1903. 

Gall-stones,  Chronic  Pancreatitis  :  Choledochotomy  ;  Cholecystectomy. 

Case  499. — Mr.  D.,  aged  fifty-nine,  seen  with  Dr.  Roper,  Leeds. 
Two  years  ago  had  an  attack  of  jaundice  with  pain,  but  no  gastro- 
intestinal disturbance ;  enlargement  of  the  liver  and  spleen.  A 
year  ago  had  a  recurrence  of  the  jaundice,  with  pain ;  these 
attacks  had  recurred  frequently  since,  and  during  the  last  few 
months  he  had  had  shivering  attacks,  with  pain  and  jaundice. 
Had  lost  8  stones  in  weight  during  the  last  few  years;  six  months 
ago  patient  had  a  strangulated  inguinal  hernia  successfully  treated 
by  herniotomy.  The  liver  was  considerably  enlarged ;  also  some 
enlargement  of  the  gall-bladder,  with  some  tenderness.  Fine 
pancreatic  crystals  in  urine. 

Operation.  —  14/4/1903.  Liver  enlarged  and  cirrhosed,  and 
there  were  a  large  number  of  adhesions  ;  a  gall-stone  the  size  of  a 
pullet's  egg  was  found  in  the  gall-bladder ;  one  the  size  of  a  rook's 
egg  in  the  common  duct  removed  by  choledochotomy ;  the  gall- 
bladder with  the  stone  was  removed  by  cholecystectomy  ;  pancreas 
enlarged. 

After-History.  —  Patient  made  a  good  recovery. 

Gall-stones  :  Cholecystotomy. 

Case  500.  —  Mrs.  \Y\,  aged  thirty-five,  seen  with  Dr.  Dobie, 
Keighley.  Two  years  ago  had  had  attacks  of  pain  over  the  liver, 
with  vomiting  ;  the  two  last  atta<  ks  of  pain  had  lasted  for  three 
or  four  days,  and  had  been  followed  by  jaundice  and  a  feeling  of 
chilliness  ;   no  di  itension  of  the  gall-bladder. 

Operation.— 15/4/1903.  Cholecystotomy;  several  stones  removed 
from  the  cystic  duct  and  gall-bladder. 

After-History. — Patient  made  a  good  recovery. 


APPENDIX  455 

Gall-stoneS  :  Cholccystoiomy. 

Case  501. — Mrs.  J3.,  aged  forty-four,  seen  with  Dr.  Dearden, 
Wyke,  for  attacks  of  pain  starting  in  the  epigastrium  and  passing 
through  to  the  hack.  For  two  years  patient  had  been  losing 
flesh.  No  jaundice,  but  a  slight  icteric  tinge  after  each  attack  ; 
no  enlargement  of  the  gall-bladder,  but  considerable  tenderness, 
and  some  enlargement  of  the  liver. 

Operation.  — 15/4/1903.  Cholecystotomy  ;  several  gall-stones 
removed  from  a  contracted  gall-bladder. 

After-History. — Good  recovery. 

Gall-stones  ;  Chronic  Pancreatitis  :  C  hole  dichotomy  and  Cholecystotomy. 

Case  502. — Miss  C,  aged  forty-three,  seen  with  Dr.  Rayner, 
Stockport.  For  nine  years  had  had  attacks  of  biliary  colic.  The 
attacks  lasted  some  hours,  and  were  followed  by  slight  jaundice, 
which  had  recently  persisted.  There  had  been  considerable  loss 
of  flesh  and  general  ill-health.    Pancreatic  crystals  found  in  urine. 

Operation. — 22/4/1903.  Cholecystotomy  and  choledochotomy  ; 
three  stones  removed  from  the  gall-bladder  and  cystic  duct,  and 
one  from  the  common  duct  by  choledochotomy  ;  duct  sutured  ; 
right  renal  pouch  drained  ;  slight  enlargement  of  pancreas. 

After-History. — Good  recovery  ;  well,  July,  1903. 

Gall-stones,  Infective  Cholangitis,  Jaundice,  Chronic  Pancreatitis  : 

Choledochotomy. 

Case  503. — Mrs.  S.,  aged  thirty-four,  seen  with  Dr.  Johnston, 
Belper.  Symptoms  of  gall-stones  for  four  years  ;  had  been  under 
treatment  for  ulcer  of  the  stomach,  but  there  had  been  no 
haematemesis.  Four  months  previously  jaundice  came  on  after 
an  attack  of  pain,  since  which  time  the  attacks  had  been  frequent 
and  always  followed  by  jaundice,  rigors,  and  fever.  On  one  occa- 
sion the  gall-bladder  was  distended.  When  seen  there  was  a  slight 
tinge  of  jaundice.  She  had  lost  3  stones  in  weight.  There 
was  an  absence  of  enlargement  of  the  liver  or  gall-bladder,  but 
marked  tenderness  over  the  gall-bladder  was  elicited.  Pancreatic 
crystals  found  in  urine. 

Operation. — 23/4/1903.  Choledochotomy;  one  large  calculus 
removed  from  the  cystic  duct,  and  some  smaller  stones  from  the 
common  duct,  through  separate  incisions  in  the  two  ducts ; 
common  duct  sutured  ;  cystic  duct  drained  ;  enlarged  pancreas. 

After -History. — Patient  made  a  good  recovery,  and  is  now  well. 

Ulceration  and  Perforation  of  Common  Bile-duct  by  Gall-stone, 
Pancreatitis  :  Drainage  of  Duct ;  Cholecystectomy. 

Case  504. — Mrs.  O.,  aged  forty-two,  seen  with  Dr.  Williams, 
Wrexham.      After   gall-stone    symptoms    extending   over    some 


456    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

months,  the  patient  had  an  acute  seizure,  followed  by  an  illness 
of  some  weeks'  duration,  associated  with  jaundice,  fever,  and 
rapid  loss  of  flesh,  there  being  decided  tenderness  and  swelling  in 
the  gall-bladder  region.     Pancreatic  crystals  found  in  urine. 

Operation. — 27/4/1903.  On  opening  the  abdomen  numerous 
adhesions  were  encountered,  and  on  separating  the  superficial 
ones  the  space  above  the  kidney,  between  it  and  the  common 
duct,  was  found  to  contain  pus  and  bile,  and  in  the  cavity  was 
a  large  gall-stone  the  size  of  a  blackbird's  egg,  which  had 
ulcerated  through  the  common  duct,  leading  to  extravasation 
of  bile.  During  the  separation  of  adhesions  and  removal  of 
the  damaged  gall-bladder  a  large  vessel  was  wounded,  and 
ligatured  with  so  much  difficulty  that  it  was  felt  safer  to  leave 
pressure-forceps  on  it  by  the  side  of  the  drainage-tube,  and  no 
attempt  was  made  to  close  the  ulcerated  opening  into  the  common 
duct.  Drainage  of  the  bile-duct  and  of  the  infected  area  was 
performed.  There  were  numerous  adhesions  between  the  liver 
and  diaphragm,  where  there  had  evidently  been  subdiaphragmatic 
peritonitis,  thus  preventing  the  liver  being  rotated,  and  making 
the  operation  extremely  difficult.     Pancreas  difficult  to  palpate. 

After- History.  —  The  patient  bore  the  operation  badly,  and 
succumbed  to  shock  the  following  day. 

Gall-stone  in  Common  Duct :  Choledochotomy  after  Cholelithotrity. 

Case  505. — Mrs.  S.,  aged  sixty-eight,  seen  with  Dr.  Evelyn, 
York.  For  twelve  years  had  suffered  from  attacks  of  biliary  colic, 
followed  by  jaundice,  which  had  lately  been  persistent  ;  consider- 
able loss  of  flesh.  The  liver  was  slightly  enlarged  ;  no  enlarge- 
ment of  the  gall-bladder. 

Operation. — 28/4/1903.  Choledochotomy;  one  large  stone  re- 
moved from  the  common  duct  after  the  concretion  had  been  crushed. 

After -History. — Good  recovery. 

Gall-stones,  Chronic  Pancreatitis  :  Cholecystotomy. 

Case  506. — Mrs.  T.,  aged  fifty,  seen  with  Dr.  Callender  and 
Mr.  Meredith,  London.  For  six  years  had  had  attacks  of  biliary 
colic,  and  during  the  last  two  months  had  had  numerous  seizures, 
followed  by  slight  jaundice,  fever,  and  collapse.  Pine  pancreatic 
crystals  in  urine. 

Operation. — 30/4/1903.  Cholecystotomy;  forty  stones  removed 
from  the  gall  bladder  and  cystic  duct.     Head  of  pancreas  swollen. 

After-History. — Good  recovery  ;  well,  July,  1903. 

Cancer  of  Liver :  Exploratory  Operation. 

Case  507. — Mrs.  M.,  aged  fifty-four,  seen  with  Dr.  Scatterty, 
Keighley.     For  two  or  three  months  the  patient  had  had  attacks 


APPENDIX  457 

of  pain  in  the  region  of  the  liver,  and  a  tumour  had  lately  been 
noticed.  There  was  a  distinct  irregular  mass  under  the  right 
costal  margin  continuous  with  the  liver  and  associated  with  a  dis- 
tended gall-bladder.     Patient  had  lost  flesh  and  looked  very  ill. 

Operation.  — 14/5/1903.  Exploratory  ;  carcinoma  of  the  liver 
and  gall-bladder  found. 

After- History. — Recovered  from  operation,  and  returned  home 
at  end  of  three  weeks  apparently  relieved. 

Biliary  Pulmonary  Fistula,  Gall-stone  impacted  in  the  Hepatic  Duct  : 

Hepato-dochotomy. 

Case  508. — Mr.  G.,  aged  twenty-eight,  sent  by  Dr.  Mathew, 
Port  Elizabeth,  South  Africa.  He  was  quite  well  up  to  April, 
1894,  when  he  had  an  attack  of  pneumonia;  six  months  later  he 
had  an  illness  accompanied  by  a  cough,  and  on  the  third  day  he 
began  to  expectorate  ;  shortly  afterwards  he  coughed  up  a  large 
quantity  of  pus  and  bile.  Before  this  attack  he  had  had  no  liver 
symptoms,  except  that  on  one  occasion  he  had  had  pain  in  the 
gall-bladder  region,  which  it  was  surmised  might  be  due  to  gall- 
stones. Since  that  time  he  had  regularly  coughed  up  bile  and 
pus,  and  he  was  thought  at  first  to  be  suffering  from  phthisis. 
He  lost  flesh  rapidly  and  had  night  sweats.  During  the  year 
before  coming  to  England  he  had  not  got  thinner,  though  the 
amount  expectorated  did  not  lessen.  An  examination  of  the  chest 
showed  no  sign  of  lung  disease,  though  the  breath -sounds 
diminished  on  the  right  side  up  to  the  seventh  rib.  The  liver  was 
decidedly  enlarged,  and  projected  3  inches  below  the  costal  margin. 
There  was  slight  jaundice.  About  1  to  ij  pints  of  extremely 
offensive  bile  and  pus  were  coughed  up  in  the  twenty-four  hours. 

Operation. — 21/5/1903.  No  cyst  discovered  in  the  liver,  which 
showed  signs  of  cirrhosis.  After  numerous  firm  adhesions  had 
been  separated,  a  gall-stone  was  found  impacted  in  the  hepatic 
duct,  and  removed  through  an  incision  in  the  duct ;  numerous 
adhesions  fixed  the  back  and  the  dome  of  the  liver  to  the 
diaphragm,  but  no  abscess  cavity  discovered  ;  drainage  of  the 
hepatic  duct  was  effected  by  a  rubber  catheter,  and  a  gauze 
drain  was  passed  to  the  neighbourhood  of  the  incised  duct.  The 
expectoration  of  bile  was  immediately  arrested,  but  offensive  pus 
was  coughed  up.  The  expectoration  of  bile  returned  on  the 
third  day,  and  then  gradually  diminished  ;  the  cough  became 
less,  and  the  purulent  expectoration  rapidly  diminished. 

After- History. — Two  months  later  the  patient  had  improved 
very  much,  was  gaining  weight  rapidly,  and  was  only  coughing 
up  a  small  quantity  of  muco-pus,  without  any  bile.     There  was 


458    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

no  jaundice,  and  all  the  bile  was  passing  into  the  bowel.  The 
wound  had  been  soundly  healed  for  a  month,  and  he  had  been 
able  to  walk  several  miles  a  day.  He  returned  to  South  Africa 
in  the  third  month,  and  has  since  reported  himself  well. 

Gall-stones  :  Cholecystotomy. 

Case  509. — Mrs.  L.,  aged  thirty-seven,  seen  with  Dr.  Gibson, 
Harrogate.  For  fifteen  years  the  patient  had  suffered  from  attacks 
of  biliary  colic  ;  lately  the  attacks  had  become  extremely  acute, 
and  patient  had  been  quite  an  invalid.  The  last  attack  was 
followed  by  jaundice,  and  the  patient  was  still  slightly  jaundiced 
at  time  of  operation.  There  was  some  enlargement  of  the  liver, 
with  acuie  tenderness  over  the  gall-bladder. 

Operation. — 25/5/1903.  Cholecystotomy  ;  numerous  stones  re- 
moved from  the  gall-bladder  and  cystic  duct. 

After-History. — Patient  made  a  good  recovery,  and  is  now  well. 

Gall-stones  :  Choledochotomy. 

Case  510. — Mrs.  B.,  aged  twenty-eight,  sent  by  Sir  Thomas 
Fitzgerald  and  Dr.  Hooper,  Melbourne,  seen  with  Dr.  J.  Prince 
Bartlett,  London.  Gall-stone  attacks  for  six  years ;  lately  the 
attacks  had  been  severe  and  frequent,  and  there  had  been  loss 
of  flesh  ;  the  gall-bladder  was  distended  and  tender. 

Operation. — 4/6/1903.  Cholecystotomy  ;  two  large  gall-stones 
removed  from  the  gall-bladder,  with  muco-pus,  and  one  stone 
removed  from  the  termination  of  the  cystic  duct  by  choledocho- 
tomy ;  duct  sutured  ;  gall-bladder  drained. 

After-History. — Patient  made  a  good  recovery,  and  is  now  well. 

Dilated    Common   Duct,    Chronic   Pancreatitis :    Cholecystotomy ; 

Choledochostomy. 

Case  511. — Miss  F.,  aged  twenty-eight,  seen  with  Dr.  Griffiths, 
Swansea.  Four  years  previously  she  had  typhoid  fever,  and  had 
never  been  well  since ;  a  year  previously  she  had  an  attack  of 
pain  followed  by  jaundice  and  some  enlargement  of  the  gall- 
bladder. She  was  operated  on  by  Dr.  Griffiths  in  June,  1902  ;  no 
gall-stones  were  found,  but  the  head  of  the  pancreas  was  much 
enlarged.  The  gall-bladder  was  drained,  and  the  wound  healed 
within  the  month.  The  patient  was  well  up  to  March,  1903, 
when  she  had  a  recurrence  of  the  jaundice,  with  sickness,  retching, 
and  pain  ;  she  became  very  ill,  and  lost  flesh  rapidly.  When  we 
saw  her  together  there  was  some  enlargement  of  the  gall-bladder, 
and  a  distinct  cystic  swelling  over  the  pancreas.  Pancreatic 
crystals  found  in  urine. 

Operation. — 4/6/1903.  Inflamed  and  distended  gall-bladder  ; 
large  cyst  on  the  inner  side  of  the  gall-bladder  containing  bile  and 


APPENDIX  45V 

pus — probably  a  dilated  common  bile-duct;  linger  passed  into  the 
cyst  reached  behind  the  stomach  and  duodenum  ;  drainage  of  the 
gall-bladder  and  of  the  cyst. 

After-History. — Patient  made  a  good  recovery  from  the  opera- 
tion and  returned  home,  but  it  was  not  considered  wise  to  leave 
out  the  tubes,  and  subsequently  a  further  operation  was  necessary. 
(Case  526.) 

Gall-stones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis  : 

Choledochotomy. 

Case  512. — Mrs.  T.,  aged  sixty-six,  seen  with  Dr.  Waterhouse, 
Hampstead.  For  many  years  had  been  subject  to  attacks  of 
biliary  colic,  with  occasional  fever  and  jaundice  ;  eighteen  months' 
freedom  until  six  weeks  ago,  when  the  attacks  recurred,  and  were 
repeated  very  frequently,  accompanied  by  rigors,  jaundice,  fever, 
and  loss  of  flesh.  When  seen,  the  patient  was  very  feeble  and 
vomiting  everything.  After  rectal  feeding  for  a  week  the 
vomiting  ceased,  and  the  pulse  improved  somewhat. 

Operation. — 5/6/1903.  Choledochotomy  and  cholecystotomy  ; 
sixty  -  six  gall-stones  removed  from  the  common  and  hepatic 
ducts,  which  were  sutured. 

After-History. — The  patient  made  a  good  recovery,  and  was  able 
to  be  on  the  sofa  within  the  month  ;  now7  well. 

Gall-stones,  Jaundice  and  Infective  Cholangitis  :  Choledochotomy. 

Case  513. — Mrs.  S.,  aged  sixty-four,  seen  with  Dr.  Whipham 
and  Dr.  Turner,  London.  Gall-stone  symptoms  for  forty  years, 
with  ague-like  attacks  and  slight  jaundice  ;  stones  regularly  found 
in  the  stools  after  the  attacks  until  three  years  ago.  Lately  the 
attacks  had  been  more  frequent,  and  were  always  followed  by 
intensification  of  jaundice,  and  associated  with  rigors  and  loss  of 
flesh  and  strength. 

Operation. — 5/6/1903.  Thirty-five  gall-stones,  with  pus  and  bile, 
removed  from  an  inflamed  gall-bladder,  and  three  gall-stones  re- 
moved from  the  common  duct  by  choledochotomy  ;  duct  sutured 
and  gall-bladder  drained  ;  very  firm  adhesions  rendered  the  opera- 
tion somewhat  difficult. 

After-History. — Patient  made  a  good  recovery,  and  is  now  well. 

Chronic  Catarrhal  Cholecystitis  :  Cholecystotomy  ;  Gastrolysis. 

Case  514. — Mr.  H.,  aged  twenty-three,  seen  with  Dr.  Child, 
London.  Had  an  attack  of  typhoid  fever  in  South  Africa  four 
years  ago,  followed  by  pain  and  tenderness  over  the  gall-bladder 
region  ;  symptoms  of  gall-stones  three  months  ago,  since  which 
time  there  had  been  recurring  attacks,  with  slight  jaundice  and 


460    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

general  ill-health  (for  which  he  had  been  invalided  home  from 
West  Africa,  in  order  to  have  an  operation  performed).  Some 
tenderness  over  the  gall-bladder,  but  no  enlargement  to  be  felt. 

Operation.  —  6  '6/1903.  Cholecystotomy  ;  no  gall-stones  found; 
extensive  adhesions  between  the  gall-bladder,  omentum,  stomach, 
and  intestine  separated  ;  gall-bladder  full  of  tenacious  mucus  and 
dark,  thick  bile,  though  a  bacterial  examination  proved  it  to  be 
sterile. 

After-History. — Patient  made  a  good  recovery,  and  is  now  well. 

Gall-stones  :  Choledochotomy  and  Cholecystotomy . 

Case  515. — Mrs.  M.,  aged  fifty-two,  seen  with  Dr.  G.  S.  Mill, 
Ossett.  Frequent  attacks  of  gall-stone  pain  for  many  years  ; 
lately  the  attacks  had  been  followed  by  jaundice  and  vomiting  ; 
slight  enlargement  of  the  liver;  no  enlargement  of  the  gall-bladder; 
no  dilatation  of  the  stomach. 

Operation. — 10/6/1903.  Cholecystotomy  and  choledochotomy; 
one  stone  removed  from  the  common  duct,  which  was  closed  by 
sutures. 

After-History.  —  Good  recovery,  and  patient  now  well. 

Gallstones  in  Common  Duct,  Jaundice  and  Infective  Cholangitis, 
Cirrhosis  of  Liver,  Chronic  Pancreatitis  :  Choledochotomy. 

Case  516.— Mr.  E.,  aged  forty-two,  seen  in  London.  Ague- 
like seizures  and  slight  jaundice,  with  great  loss  of  flesh  ;  very 
little  pain,  though  some  pain  always  preceded  the  shivers,  and 
then  the  jaundice  became  deeper  ;  bulky,  frequent  stools,  con- 
taining fat  and  undigested  muscle ;  urine  contained  pancreatic 
crystals,  but  no  sugar  or  albumin. 

Operation. — 19/6/1903.  Choledochotomy;  several  gall-stones 
crushed  in  the  common  duct,  and  removed  by  the  scoop  through 
an  opening  in  the  duct  ;  the  gall-bladder  and  common  duct  were 
drained  ;  the  pancreas  was  much  enlarged  (chronic  pancreatitis) ; 
liver  cirrhotic.  There  was  considerable  oozing  of  blood  from  the 
wound  from  the  sixth  to  the  eighth  days,  arrested  by  calcii  chlorid. 
in  large  doses. 

After  History. — The  patient  made  a  good  recovery,  and  left  the 
surgical  home  with  the  wound  healed.  It  subsequently  reopened 
and  discharged  bile  ;  weight  has  been  gained,  and  he  is  decidedly 
better,  though  not  well.  December  iS,  Mr.  E.  called  to  say  that 
the  fistula  had  closed  on  November  17,  and  that  he  had  gained  2 
stones  6  pounds  nnce  the  operation. 

Gall-stones  :    Cholecystotomy. 
Case  517.      Miss  W.,  aged  forty-three,  seen  with  Dr.  Clayton, 
Hampstead.     In  September,  1900,  the  patient  had  an  attack  of 


APPENDIX  461 

pain  in  the  right  side,  followed  by  jaundice.  During  the  next  four 
months  she  had  several  attacks,  and  a  loss  of  ij  stones  in  weight. 
She  was  free  from  acute  seizures  until  March,  1902,  when  she 
had  a  similar  severe  attack.  The  attacks  had  been  frequent 
and  severe  since,  and  were  followed  by  jaundice. 

Operation. — 25/6/1903.  Enlargement  of  the  right  lobe  of  the 
liver;  gall-bladder  thickened,  containing  nine  gall-stones  and  muco- 
pus ;  cholecystotomy. 

After -History. — Patient  made  a  good  recovery,  and  is  now  well. 

Gall-stones,  Ulcerative  Cholecystitis,  Abscess  of  Liver  :  Cholecystectomy. 

Case  518. — John  E.,  aged  sixty-seven,  seen  at  the  Leeds  Infir- 
mary. For  forty  years  had  had  attacks  of  indigestion  ;  six  months 
before  admission  had  a  severe  attack  of  biliary  colic,  followed  by 
jaundice,  itching,  and  clay-coloured  motions.  The  attacks  had  been 
frequent  since.     No  jaundice  on  admission. 

Operation. — 30/6/1903.  Many  adhesions  found  ;  ulcerative  chole- 
cystitis ;  three  stones  removed  from  gall-bladder ;  gall-bladder 
dissected  away  from  the  liver.  An  abscess  found  in  substance  of 
liver  evacuated,  curetted,  and  packed  with  gauze. 

After-History. — Patient  made  a  good  recovery,  and  remains 
well. 

Gall-stones,  Suppurative  Cholangitis,  Parotitis,  and  Septicemia  : 

Choledochotomy. 

Case  519. — Mrs.  L.,  aged  sixty-five,  seen  with  Sir  William 
Broadbent  and  Dr.  Bousfield.  Patient  extremely  ill,  deeply 
jaundiced,  and  in  a  state  of  septicaemia,  with  daily  rigors,  high 
fever,  and  acute  parotitis  on  the  left  side.  There  was  also  mitral 
disease  and  slight  albuminuria.  This  acute  condition  had  come 
on  within  the  past  fortnight,  though  the  patient  gave  a  history  of 
gall-stone  attacks  for  years. 

Operation. — 10/7/ 1903.  The  common  duct  was  enormously 
dilated,  and  on  incision  a  quantity  of  extremely  offensive  pus 
and  bile  was  discharged  ;  this  poured  out  of  the  ducts  in  the  liver. 
Three  large  gall-stones,  the  size  of  rook's  eggs,  were  removed  from 
the  common  duct,  and  a  number  of  small  ones,  the  duct  itself 
being  drained  ;  the  gall-bladder  was  quite  small.  After  completing 
the  operation,  the  parotid  was  incised  and  drained. 

After -History. — The  operation  was  well  borne,  and  the  next 
morning  the  patient  had  a  normal  temperature,  and  expressed 
herself  as  doing  well.  At  lunch-time  of  the  following  day  she 
appeared  to  be  doing  well,  when  suddenly  the  heart  became  em- 
barrassed, and  she  died  rapidly,  before  any  help  could  be  sum- 
moned, probably  from  thrombosis.    An  examination  by  Mr.  Eastes 


462    DISEASES  OF  THE  GAEL-BLADDER  AND  BILE-DUCTS 

of  the  purulent  bile  removed  at  the  time  of  operation  showed  it  to 
contain  the  Bacillus  coll  communis  in  large  numbers ;  next  in 
numbers  were  streptococci,  and  another  rather  fine  bacillus,  which 
appeared  to  grow  anaerobically  only,  and  there  was  a  spore-bearing 
organism,  probably  the  Bacillus  coli putvifacies. 

Gall-stones,  Perceptible  Tumour  of  Gall-bladder  :   Cholecystotomy. 

Case  520. — Mrs.  R.,  aged  seventy-two,  seen  with  Dr.  Donald 
Hood  and  Dr.  Bartlett,  of  London,  and  Dr.  Greaves,  of  Bourne- 
mouth, on  account  of  a  tumour  in  the  gall-bladder  region.  There 
had  been  a  history  of  gall-stone  attacks  fourteen  years  and  seven 
years  ago,  since  which  time,  beyond  a  little  uneasiness  in  the 
gall-bladder  region,  there  had  been  no  pain  until  a  recent  attack 
in  Bournemouth.  As  the  tumour  was  increasing,  operation  was 
advised. 

Operation.  — 14/7/1903.  Cholecystotomy;  thirty-four  gall-stones 
were  removed  from  the  gall-bladder,  one  being  the  size  of  a 
walnut. 

After-History. — Patient  made  a  good  recovery  ;  well,  November, 
1903. 

Cancer  of  Gall-bladder  and  Liver  :  Laparotomy. 

Case  521. -—Mrs.  W.,  aged  forty,  seen  with  Dr.  McNeil,  of 
Bridlington,  on  account  of  a  tumour  on  the  right  of  the  abdomen. 
The  patient  had  complained  of  pain  for  some  months,  and  had 
noticed  a  swelling,  though  she  had  not  mentioned  this  to 
Dr.  McNeil  until  a  week  before  I  saw  her.  There  was  a  trace  of 
albumin  in  the  urine,  and  a  question  as  to  the  presence  of  slight 
ascites.     The  tumour  was  nodular  and  hard. 

Operation. — 2 1/7/ 1903.  Exploratory  operation  was  performed, 
when  malignant  disease  of  the  gall-bladder  was  found,  associated 
with  secondary  nodules  in  the  liver  and  slight  ascites.  The 
abdomen  was  closed,  nothing  further  being  done. 

After -History. — Patient  recovered  from  the  operation. 

Cancer  of  Ampulla  of  Vater  with  Pancreatitis  (?). 

Case  522. — Mr.  B.,  aged  thirty-seven,  seen  with  Dr.  Thomson, 
Lincoln,  on  account  of  extremely  rapid  loss  of  weight  (4  stones) 
and  strength,  associated  with  very  deep  jaundice.  There  was  no 
history  of  paroxysmal  pain,  though  he  had  been  liable  to  curious 
epigastric  distress,  which  he  described  as  indigestion.  The  liver 
was  enormous  in  size,  and  reached  to  the  anterior  superior  spine 
of  the  ileum.  The  enlarged  gall-bladder  could  be  easily  felt,  and 
a  doubtful  ascitic  wave.     The  motions  contained  fat  and  muscle 


APPENDIX  463 

fibre,  but  no  bile,  the  stools  being  bulky  and  pale,  and  occurring 
two  or  three  times  every  day. 

Operation. — 23/7/1903.  Cholecystotomy  was  performed  in  order 
to  try  to  give  relief  to  the  jaundice.  There  were  some  adhesions 
along  the  cystic  duct,  and  there  was  a  distinct  swelling  of  the 
pancreas,  with  definite  hardness  at  one  point,  as  if  there  might  be 
growth  starting  in  the  ampulla  of  Vater  and  invading  the  pancreas. 
No  stones  could  be  felt.  The  bile  that  drained  away  was  in- 
tensely dark,  but  by  the  third  day  it  had  cleared  very  materially, 
and,  at  the  same  time,  his  colour  was  improving.  The  wound 
healed  by  first  intention  ;  the  tube  came  away  on  the  seventh 
day,  and  the  bile  continued  to  drain  into  the  dressings.  On  the 
evening  of  the  seventh  day  he  had  what  he  called  his  indigestion 
pain,  which  appeared  to  be  cardiac,  though  the  pulse  remained 
quite  normal  and  regular.  On  the  morning  of  the  eighth  day, 
immediately  after  he  had  been  seen  by  my  colleague,  Mr.  Armour, 
who  had  taken  the  pulse  and  found  it  80,  he  suddenly  became 
collapsed,  and  died  within  ten  minutes,  apparently  from  heart 
failure.     Unfortunately,  a  post-mortem  could  not  be  obtained. 

The  bowels  had  been  moved  quite  satisfactorily  each  day,  and 
the  bile  was  gradually  returning  in  the  motions.  An  examination 
of  the  urine  by  Mr.  Cammidge  showed  pancreatic  crystals,  not 
pointing  to  malignant  disease;  but  whether  it  was  chronic  pancrea- 
titis secondary  to  cancer  of  the  ampulla  of  Yater,  or  cancer  of  the 
head  of  the  pancreas,  must,  unfortunately,  remain  doubtful  in  the 
absence  of  an  autopsy  which  could  not  be  obtained. 

Gall-stones  in  Gall-bladder  and  Common  Duct :  Cholecystotomy  and 
CholedocJiotomy  ;  Duodenal  Fistula  repaired. 

Case  523. — Miss  H.,  aged  fifty,  seen  with  Dr.  Haines,  London, 
and  Dr.  Ashley  Cummins,  Cork,  on  September  14,  1903.  Twenty 
years'  history  of  occasional  attacks  of  gall-stones.  For  the  last 
four  years  the  attacks  had  been  more  frequent,  and  since  Christmas 
jaundice  had  never  completely  passed  away,  though  in  the  interval 
it  was  quite  slight.  In  the  early  months  of  the  year  the  seizures 
were  always  accompanied  by  ague-like  attacks,  which  had  been 
more  marked  lately.  Swelling  in  the  right  lobe  of  the  liver  ;  rigid 
rectus;  marked  tenderness;  slight  jaundice. 

Operation. — 25/9/1903.  Two  gall-stones  removed  from  the  gall- 
bladder, which  was  inflamed  and  thickened,  and  two  by  chole- 
dochotomy  from  a  dilated  common  duct,  which  was  sutured,  the 
opening  in  the  gall-bladder  being  used  for  drainage.  A  minute 
gall-bladder  duodenal  fistula  was  discovered,  and  the  opening  in 
the  duodenum  wras  closed  by  a  purse-string  suture. 

After-History. — Good  recovery.  Patient  quite  well,  November, 
1903. 


464    DISEASES  OE  THE  GALL-BLADDER  AND  BILE-DUCTS 

Cancer  of  Pancreas  and  Liver  :  Exploratory  Operation. 

Case  524. — Mr.  M.,  aged  fifty-one,  seen  with  Dr.  Roughton, 
New  Barnet,  September  12,  1903,  suffering  from  jaundice  and 
three  abdominal  fistulae  in  the  epigastrium  and  right  hypochon- 
drium,  two  of  which  were  discharging  bile  and  pus,  and  which 
were  the  result  of  previous  operations,  in  which  an  abscess  had 
been  evacuated  and  some  gall-stones  removed  from  the  gall- 
bladder. There  had  been  great  loss  of  flesh  and  some  fever,  the 
illness  having  continued  from  Christmas,  1901,  though  the 
jaundice  had  only  been  present  since  the  last  operation,  two 
months  before.  An  examination  of  the  faeces  by  Dr.  P.  J. 
Cammidge  showed  an  excess  of  fat  and  muscle  fibre.  The  urine 
did  not  contain  any  albumin  or  sugar,  but  numbers  of  pancreatic 
crystals  soluble  in  from  four  to  five  minutes,  therefore  pointing  to 
malignant  disease.  As  the  patient  was  suffering  from  irregular 
fever,  with  attacks  of  pain  suggestive  of  concretion  in.  the  common 
duct,  and  manifestly  running  down,  and  as  he  was  anxious  to  see 
if  the  obstruction  in  the  common  duct  could  be  relieved,  a  further 
operation  was  undertaken. 

Operation. — 3/10/1903.  Well-marked  malignant  disease  of  the 
pancreas  and  liver  was  found.  The  abdomen  was  therefore 
closed. 

After-History.  —  Recovery  from  operation.  In  December  he 
was  gradually  losing  ground,  though  still  hopeful  of  recovery. 

Gall-stones,  Kinking  of  Bile-ducts  by  Movable  Kidney,  Pyloric  Stenosis  : 
Cholecystotomy  ;  Gastrolysis  ;  Pylorodiosis  ;  Nephropexy. 

Case  525. — Mrs.  F.,  aged  sixty,  seen  with  Dr.  Orr,  Putney, 
September  2,  1903.  Twelve  years  ago  she  passed  gall-stones, 
and  had  on  one  or  two  occasions  since  had  attacks  of  pain,  after 
which  gall-stones  had  been  discovered  in  the  motions,  though  she 
had  never  been  jaundiced.  A  year  ago  she  began  to  suffer  from 
paroxysmal  pain  in  the  gall-bladder  region,  since  when  there  had 
been  great  loss  of  flesh  and  at  times  slight  jaundice.  When  1 
saw  her  there  was  tenderness  over  the  gall-bladder  region, 
marked  dilatation  of  the  stomach,  and  an  easily-movable  tumour, 
which  we  diagnosed  as  a  floating  kidney.  Exercise  brought  on 
pain,  so  that  the  patient  was  confined  to  the  bed  or  sofa,  and 
looked  extremely  ill  and  thin. 

Operation. — 10/10/1903.  The  tumour  proved  to  be  a  floating 
kidney,  with  a  tendency  to  hydronephrosis.  The  gall-bladder  was 
enlarged,  and  contained  thick  bile  and  mucus.  It  was  evidently 
dragged  on  by  the  kidney  so  as  to  produce  kinking  of  the  bile- 
ducts.  The  pylorus  was  contracted  and  adherent  to  the  gall- 
bladder.    The  adhesions  were  separated,  and  the  pylorus  dilated 


APPENDIX  465 

by  Hahn's  operation.     Cholecystotomy  was  performed,  and  after- 
wards nephropexy. 

Aftev-Histovy. — Good  recovery.     Patient  well,  December,  1903. 

Chronic  Pancreatitis,  Dilated  Common  Bile-duct,  Cholecystitis  : 
Cholecystectomy ;  Choledochenterostomy. 

Case  526. — Miss  F.,  aged  twenty-eight,  seen  with  Dr.  Griffiths, 
Swansea.  Since  the  former  operation  there  had  continued  to 
drain  away  from  the  tube  in  the  dilated  common  bile-duct 
20  to  30  ounces  of  bile.  No  bile  entered  the  bowel,  and  from 
the  tube  leading  into  the  gall-bladder  4  to  6  ounces  of  clear 
mucus  drained  away  each  day.  The  patient  was  thin  and  feeble, 
had  no  appetite  for  food,  and  was  unable  to  digest  anything 
beyond  a  little  milk.  An  examination  of  the  urine  showed  the 
absence  of  albumin  and  sugar,  but  the  presence  of  pancreatic 
crystals,  which  dissolved  in  from  three-quarters  to  one  minute. 
The  fasces  contained  fat  and  muscle  fibre.  An  examination  of  the 
bile  by  Dr.  Eastes  was  reported  to  contain  numerous  bacilli, 
which  proved  to  be  the  B.  entevitidis  of  Gartner. 

Operation. — 8/10/1903.  Head  of  pancreas  found  to  be  enlarged, 
but  no  concretion  was  felt  in  it  or  in  the  common  bile-duct.  Gall- 
bladder completely  excised,  the  cystic  duct  being  ligatured ;  the 
dilated  common  bile-duct  was  then  connected  to  the  duodenum 
by  means  of  a  decalcified  bone  bobbin,  and  the  wound  was  closed. 
The  same  evening  the  patient  expressed  herself  as  feeling  hungry 
for  the  first  time  since  her  illness,  this  apparently  being  dependent 
on  the  bile  and  pancreatic  fluid  entering  the  intestine.  She 
straightway  began  to  absorb  whatever  nourishment  was  taken, 
had  her  bowels  moved  on  the  second  day,  gained  strength, 
resumed  her  natural  colour,  and  made  such  a  rapid  convalescence 
that  she  returned  home  within  the  month,  having  gained  7  pounds 
in  weight  since  the  operation. 

Gall-stones,  Chronic  Pancreatitis  :  Choledochotomy ;  Cholecystotomy. 

Case  527. — Mrs.  C,  aged  forty-six,  seen  with  Dr.  Tate,  High- 
gate,  September  29,  1903.  Symptoms  of  gall-stones  for  two  years. 
Six  months  ago  had  a  severe  attack  of  pain  followed  by  jaundice, 
which  lasted  for  six  weeks,  and  slight  jaundice  had  continued. 
Since  that  time  had  had  several  shivering  attacks,  and  had  lost 
3  stones  in  weight. 

Operation. — 14/10/1903.  Riedel's  lobe  well  developed  ;  adhesions 
very  numerous  ;  shrunken  gall-bladder  discovered  containing  no 
gall-stones ;  head  of  pancreas  enlarged,  and  hardness  felt  behind 
it.  Common  duct  opened,  and  scoop  passed  down  the  ampulla 
of  Vater,  from  which  a  gall-stone  the  size  of  a  haricot  bean  was 

30 


466    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

removed.     After  this  a  probe  readily  passed  into  the  duodenum. 
The  common  duct  sutured,  gall-bladder  drained. 

After-History. — Uninterrupted  recovery.     Patient  up  at  the  end 
of  three  weeks.     Well,  December,  1903. 


Cancer  of  Gall-bladder  and  Liver  :  Hepatectomy  and  Cholecystectomy. 

Case  528. — Mrs.  R.,  aged  fifty-seven,  seen  with  Dr.  Gregor, 
Penryn,  Cornwall.  The  patient,  who  had  had  a  cholecystotomy 
for  gall-stones  February  26,  1902  (Case  422),  said  that  she  had 
been  quite  well  up  to  two  months  ago,  except  for  pain  over  the 
gall-bladder.  She  had  had  none  of  the  old  attacks,  but  on  one 
occasion  there  had  been  a  slight  ague-like  seizure.  On  examina- 
tion, a  tender  lump  could  be  felt  in  the  gall-bladder  region.  As 
the  patient  had  pain  on  movement  which  necessitated  her  resting, 
and  as  her  general  health  was  failing,  an  operation  was  advised. 

Operation. — 19/ 10/ 1903.  The  gall-bladder  was  found  the  size  of 
a  small  hen's  egg,  full  of  solid  material.  On  incising  it,  the 
swelling  was  found  to  be  new  growth,  which  was  infiltrating  the 
contiguous  parts  of  the  liver.  The  gall-bladder  and  adjoining 
part  of  the  liver  were  removed  by  a  wedge-shaped  incision.  The 
cystic  duct  was  divided  and  ligatured  well  beyond  the  disease. 
The  bleeding  from  the  cut  liver  surface  was  isolated  by  means  of 
continuous  catgut  sutures  ;  the  stump  of  the  cystic  duct  was 
covered  with  omentum.  A  small  drain  was  inserted,  which  was 
removed  on  the  second  day.  The  wound  healed  by  first  intention, 
and  the  patient  left  the  surgical  home  at  the  end  of  three  weeks. 


Chronic  Pancreatitis  :  Cholecystenterostomy. 

Case  529. — Mrs.  W.,  aged  fifty-seven,  seen  with  Dr.  Roxburgh, 
Troon.  The  patient  had  had  two  operations  previously  in 
Glasgow.  On  the  occasion  of  the  first  operation  in  September, 
1902,  a  number  of  gall-stones  were  removed  from  the  gall-bladder, 
which  was  drained,  but  since  the  wound  had  healed  the  attacks 
had  been  repeated  as  before.  A  second  operation  was  undertaken 
by  the  same  surgeon  without  finding  anything  definite.  After  the 
wound  had  healed  the  attacks  again  returned,  and  the  subsequent 
history  up  to  the  time  of  my  seeing  her  was  that  she  had  almost 
daily  attacks  of  pain,  followed  by  slight  jaundice,  and  on  five  or 
six  occasions,  usually  at  intervals  of  a  month,  she  had  had  violent 
seizures  necessitating  hypodermic  injections  of  morphia.  About 
five  weeks  ago  the  pain  was  so  violent  as  to  cause  her  to  faint, 
and  just  before  coming  to  London  another  violent  seizure,  accom- 


APPENDIX  467 

panied  by  collapse,  occurred.  A  rigor  followed  each  attack,  the 
temperature  rising  nightly  to  1010  F.  or  1020  F.  She  was  rapidly 
losing  flesh  and  strength.  An  examination  by  Dr.  Cammidge 
showed  no  albumin  or  sugar,  but  well-marked  pancreatic  crystals, 
which  dissolved  in  from  one  to  one  and  a  half  minutes,  render- 
ing the  diagnosis  of  chronic  pancreatitis  pretty  certain. 

Operation.  —  20/10/1903.  Adhesions  were  most  extensive. 
There  was  well-marked  enlargement  and  hardness  of  the  pancreas 
along  its  whole  length,  but  it  was  not  nodular.  The  common 
duct  was  carefully  examined,  but  found  to  be  free  of  concretions, 
and  on  opening  the  gall-bladder  a  probe  was  passed  through  it, 
and  the  cystic  and  common  ducts,  into  the  duodenum.  While  the 
probe  was  in  position  the  pancreas  was  manipulated,  and  found 
to  compress  the  duct,  thus  accounting  for  the  obstruction. 
Cholecystenterostomy  was  therefore  performed,  the  union  being 
effected  to  the  colon  by  means  of  a  decalcified  bone  bobbin.  At 
the  time  of  operation  the  gall-bladder  was  separated  from  the  liver 
in  order  to  make  it  reach  the  bowel  without  tension.  For  a  few 
days  after  operation  bile  was  discharged  from  the  torn  liver 
surface  in  free  quantities,  but  there  was  no  leakage  from  the 
newly-joined  viscera.  As  the  bile  obtained  a  free  passage  into  the 
bowel  it  gradually  ceased  being  discharged  from  the  liver,  and  the 
tube  was  able  to  be  left  out  at  the  end  of  ten  days.  The  wound 
healed  by  first  intention,  and  the  patient  was  up  at  the  end  of 
three  weeks.  She  was  then  able  to  take  and  digest  her  food,  and 
has  since  been  quite  free  from  her  old  attacks. 

Cirrhosis  of  Liver,  Deep  Jaundice,  Enlarged  Pancreas,  Tumour  of 
Portal  Fissure  (?  malignant) :  Cholecystotomy. 

Case  530. — Mr.  C,  aged  fifty,  seen  with  Dr.  Southern,  Derby. 
Had  had  doubtful  attacks  of  painful  indigestion  during  the  past 
few  years,  but  no  definite  attack  till  Christmas,  1902,  when  he 
was  seized  with  a  dull  pain  in  the  epigastrium,  accompanied  by 
shivering,  and  followed  by  jaundice,  which  persisted.  During  the 
interval  he  had  steadily  lost  flesh  and  strength,  and  had  had  a 
number  of  similar  attacks.  At  the  beginning  of  October  a  severe 
rigor,  followed  by  a  temperature  of  1020  F.  and  an  intensification  of 
the  jaundice,  left  him  very  much  enfeebled.  An  examination  showed 
some  tenderness  in  the  gall-bladder  region,  but  no  muscular 
rigidity  and  no  tumour  could  be  felt.  He  was  then  deeply 
jaundiced  and  very  ill.  An  examination  of  the  faeces  showed  no 
undigested  fat  or  muscle  fibre ;  only  1  per  cent,  of  fat  by  weight 
being  present.  The  urine  showed  no  sugar  or  albumin,  and, 
curiously,  no  bile  pigments.  Some  pancreatic  crystals  were  dis- 
covered, which  were  rather  long  in  dissolving. 

30—2 


468    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Operation. — 23/10/1903.  Well-marked  cirrhosis  of  the  liver 
discovered.  A  large  vein  the  size  of  the  brachial  seen  in  broad 
ligament  of  liver  ;  hard  nodular  tumour  discovered  in  portal 
fissure  close  to  the  Spigelian  lobe  ;  pancreas  considerably  enlarged 
and  hard  over  the  whole  length,  and  embracing  common  bile- 
duct.  No  gall-stones  found  ;  gall-bladder  distended  with  bile. 
On  opening  the  gall-bladder,  a  probe  could  be  passed  through  the 
common  duct  into  the  duodenum.  Cholecystotomy  performed 
for  drainage.  Adhesions  between  gall-bladder,  colon,  and  duo- 
denum divided.  Omentum  fixed  to  abdominal  wall  to  encourage 
collateral  circulation.  The  omental  fat  was  indurated  and  un- 
healthy, and  there  was  a  question  as  to  spots  of  fat  necrosis.  The 
operation  was  badly  borne,  and  the  pulse  was  very  feeble  towards 
the  end  of  it ;  afterwards  there  was  free  oozing  of  blood,  which 
was  stopped  by  the  administration  of  chloride  of  calcium  in  re- 
peated doses.  Subsequently  the  patient  made  poor  progress,  and 
though  there  was  no  distension  or  other  signs  of  peritonitis,  and 
no  elevation  of  temperature,  he  gradually  got  weaker,  and  died 
four  days  later.     Unfortunately,  no  autopsy  could  be  obtained. 

Gall-stone  in  Common  Duct :  Choledochotomy. 

Case  531. — Mr.  S.,  aged  sixty-five,  seen  with  Dr.  Finch  Haines, 
Highgate.  For  two  years  had  been  subject  to  occasional  attacks 
of  epigastric  pain.  In  January,  1903,  a  severe  attack  was  followed 
by  jaundice,  since  which  time  he  had  rapidly  lost  weight,  and  the 
jaundice  had  never  disappeared.  Pain  after  food  had  been  a 
marked  feature.  He  had  never  vomited  blood  or  had  melana. 
There  was  no  dilatation  of  the  stomach,  and  no  evidence  of 
tumour.  The  recti  were  rigid.  He  was  seen  by  a  physician,  who 
diagnosed  cancer  of  the  pancreas.  An  examination  of  the  urine  by 
Dr.  Cammidge  showed  an  entire  absence  of  pancreatic  crystals. 

Operation. — 24/10/1903.  Gall-stone  the  size  of  a  filbert  dis- 
covered in  common  duct,  and  removed  through  an  incision  which 
was  afterwards  sutured.     Gall-bladder  drained. 

After-History. — Recovery  uninterrupted.     Patient  now  well. 

Suppurating  Hydatid  discharging  into  Bile-ducts,  Infective  Cholangitis, 
Chronic  Pancreatitis :  Cholccystcnicrostomy. 
Cask  532. — Mr.  K.,  aged  twenty-six,  residing  at  Bedford,  Cape 
Colony,  was  sent  to  me  by  Dr.  Ross,  October  26,  1903.  He  gave 
a  history  of  gall-stone  attacks  for  five  or  six  years,  each  attack 
having  been  followed  by  jaundice.  On  April  15  an  operation  was 
performed  on  him  in  Cape  Colony,  when  a  cholecystotomy  was 
done  and  some  gall-stones  were  removed.  The  operation  was  a 
very  difficult  one,  on  account  of  adhesions,  and  lasted  three  hours. 


APPENDIX  4<V> 

He,  however,  made  a  good  recovery  ;  but  on  July  i  he  had  another 
severe  attack  of  pain  followed  by  jaundice,  which  had  persisted. 
The  liver  was  much  enlarged,  and  an  abscess  was  suspected, 
as  he  became  very  feverish,  the  temperature  every  night  being 
1030  F.,  though  normal  in  the  morning.  He  had  numerous  shiver- 
ing attacks,  and  constant  pain  and  tenderness.  On  August  14, 
after  an  unusually  severe  seizure,  he  was  extremely  ill,  and  was 
said  to  have  congestion  of  the  middle  lobe  of  the  liver.  In  July 
and  later  small  translucent  sacs,  bile-stained  and  containing  water, 
were  noticed  in  the  motions,  together  with  masses  of  mucus, 
leaving  very  little  doubt  that  hydatid  cysts  were  being  discharged 
from  the  bile  passages.  He  improved  somewhat  on  the  voyage, 
but  when  he  arrived  in  England  he  looked  extremely  ill,  was 
deeply  jaundiced,  and  very  feeble.  An  examination  of  the  faeces 
was  made  by  Dr.  Cammidge,  who  reported  :  fat  4  to  5  per  cent. 
by  weight,  but  no  muscle  fibres  or  fat  globules  found.  The 
urine  showed  crowds  of  pancreatic  crystals  soluble  in  half  to  one 
minute,  but  there  was  an  absence  of  sugar  or  albumin.  On 
examining  the  abdomen,  the  liver  was  found  to  be  much  enlarged, 
and  there  was  marked  tenderness  at  the  epigastrium. 

Operation. — 2/11/1903.  Liver,  gall-bladder,  and  other  viscera 
adherent  to  surface  of  abdomen,  so  that  on  section  it  was  most 
difficult  to  find  the  peritoneal  cavity.  After  a  short  time  the 
viscera  were  defined,  the  gall-bladder  isolated,  and  the  pancreas 
and  common  bile-duct  palpated.  The  pancreas  was  found  to  be 
very  much  enlarged  and  thickened,  and  to  be  compressing  the 
common  duct.  The  glands  all  along  the  duct  were  enlarged 
and  hard,  and  about  the  size  of  filberts — some  larger.  On  the 
centre  of  the  under  surface  of  the  liver  was  an  indurated  area,  as 
if  there  might  have  been  an  abscess  or  hydatid  cyst  there,  which 
had  emptied  itself,  but  no  fluctuation  could  be  detected  and  no 
bogginess.  As  bile  was  in  the  gall-bladder  under  some  tension, 
and  no  gall-stone  could  be  felt  in  the  common  duct,  the  gall- 
bladder was  connected  to  the  duodenum  by  means  of  a  Murphy's 
button. 

A ftev -History. — The  patient  bore  the  operation  well,  and  made 
an  uninterrupted  recovery.  He  was  able  to  leave  for  the  seaside 
within  the  month  and  is  now  quite  well. 

Gall-stones  in  Common  Duct,  Chronic  Pancreatitis  :  Choledoclwtomy. 
Case  533. — Mr.  H.,  aged  fifty-seven,  seen  with  Dr.  Mitchell, 
Guildford.  The  patient  had  resided  for  years  in  India,  where  he 
suffered  from  fever  and  had  a  greatly  enlarged  spleen.  There 
was  a  history  of  loss  of  flesh  for  some  months,  and  a  sudden 
onset   of  pain  associated  with  fever  and  followed  by  jaundice  in 


470    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

July,  1903.  Ague  organisms  were  found  in  the  blood  at  that 
time.  From  that  time  onward  he  had  been  extremely  ill  and  had 
lost  flesh  very  rapidly.  In  the  interval  there  had  been  several 
attacks  of  pain.  When  I  saw  him  there  was  jaundice,  though 
not  very  intense.  The  spleen  was  enlarged  nearly  to  the  umbilicus, 
and  the  liver  reached  to  the  same  level.  The  gall-bladder  was 
enlarged,  but  not  tender,  and  there  was  no  rigidity  of  the  recti. 
His  pulse  was  feeble,  intermittent,  and  slow.  The  case  did  not 
seem  at  all  a  favourable  one  for  operation,  but  it  was  decided 
to  have  the  urine  examined,  when  pancreatic  crystals  were  dis- 
covered, dissolving  in  one  minute  and  leading  to  the  diagnosis 
of  chronic  pancreatitis.  Pankreon  tabloids  were  prescribed  wTith 
general  treatment,  under  which  some  improvement  occurred,  and 
when  I  saw  him  again  I  thought  him  decidedly  better.  The  liver 
was  less  in  size  but  the  spleen  could  be  felt  considerably  enlarged. 

Operation. — 5/11/1903.  The  liver  was  found  to  be  enlarged, 
dark,  and  granular,  as  if  in  the  first  stage  of  cirrhosis.  Firm 
adhesions  of  the  omentum  to  the  gall-bladder  were  ligatured  off 
and  some  of  them  separated.  The  gall-bladder  itself  was  shrunken 
and  practically  obliterated.  A  rounded  gall-stone  the  size  of  a 
small  walnut  was  discovered  in  the  common  duct,  from  which  it 
was  removed  through  an  incision  which  was  sutured.  A  probe 
readily  passed  into  the  duodenum.  The  pancreas  was  consider- 
ably enlarged  and  pressed  on  to  the  common  duct,  but  did  not 
embrace  it.  It  was,  therefore,  not  felt  necessary  to  drain  the 
common  duct. 

After-History. — No  shock  followed  the  operation,  and  a  week 
later  the  wound  had  closed,  except  for  a  small  sinus  where  the 
drain  had  been.  He  completely  lost  his  jaundice  and  returned 
home  well  in  five  weeks. 

Chronic  Pancreatitis,  Jaundice  :   Chokcystotomy. 

Case  534. — Mrs.  J.,  aged  forty-two,  seen  with  Dr.  Harold. 
History  of  jaundice  for  three  years  with  loss  of  2  stones  in  weight. 
She  had  been  subject  to  painful  indigestion,  but  gave  no  history  of 
colic  or  severe  pain.  Itching  of  the  skin  was  a  prominent  feature. 
As  the  patient  was  very  thin,  it  was  easy  to  palpate  the  epigas- 
trium, and  a  swelling  could  be  felt  in  the  region  of  the  pancreas, 
with  well-marked  tenderness.  The  liver  was  very  little  enlarged 
and  not  hard.  Pancreatic  crystals  were  found  in  the  urine,  dis- 
solving in  half  a  minute,  and  muscle  fibres  with  3  per  cent,  of  fat 
in  the  motions,  rendering  the  diagnosis  of  chronic  pancreatitis 
pretty  certain. 

Operation. — 4/11/1903.  Gall-bladder  small,  the  common  duct 
somewhat  dilated ;  the  duodenum  and  colon  both  adherent  to 
the  liver,  and  separated  with  difficulty.    The  head  of  the  pancreas 


APPENDIX  47i 

was  found  to  be  enlarged,  and  a  large  accessory  pancreas  was  seen 
in  front  of  the  common  bile-duct.  Another  lobe  was  felt  behind 
the  common  bile-duct.  At  first  these  were  taken  to  be  very  large 
lymph  glands,  but  on  a  more  careful  examination  they  proved  to 
be  pancreatic  tissue,  apparently  pressing  on  the  common  duct. 
No  gall-stones  discovered.  Cholecystotomy  performed  for  drain- 
age of  the  ducts. 

After-History. — Good  recovery  from  operation,  but  returned  home 
on  the  fifth  week  wearing  the  tube,  as  when  it  was  left  out  the  jaun- 
dice returned  and  with  it  intense  pruritus.    Doing  well,  Jan.,  1904. 

Kinking  of  Common  Bile-duct  due  to  Adhesions,  Catarrh  of  the 
Pancreas  and  Gall-bladder  :  Cholecystotomy. 

Case  535. — Dr.  B.,  aged  thirty-nine,  seen  with  Dr.  Armstrong, 
Buxton.  Had  suffered  from  indigestion  for  years,  but  had  the 
first  severe  attack  of  biliary  colic  in  July,  1899,  when  gall-stones 
were  passed,  since  which  time  the  attacks  had  been  frequent, 
and  recently  much  more  acute,  frequently  necessitating  the  use 
of  morphia  ;  a  slight  icteric  tinge  accompanied  the  attacks.  Pan- 
creatic crystals  found  in  urine. 

Operation. — 23/11/1903.  A  thickened  gall-bladder  was  found, 
the  walls  being  much  hypertrophied  and  adherent  to  the  adjoining 
organs.  A  specially  firm  band  extended  from  the  middle  of  the 
common  duct  to  the  under  surface  of  the  liver,  producing  a  well- 
marked  kink  of  the  duct.  The  cystic  duct  was  pouched.  Xo 
gall-stones  were  discovered.  The  gall-bladder  was  drained  of 
a  quantity  of  thick  dark  bile  and  mucus. 

After- History. — Good  recovery. 

Gall-stones,  Catarrh  of  the  Gall-bladder :  Cholecystotomy. 

Case  536. — Mrs.  C,  aged  forty,  seen  with  Dr.  Atkinson, 
Hornsey.  The  patient  had  complained  of  pain  over  the  right 
side  of  the  abdomen  for  some  months,  though  a  tumour  had 
only  lately  been  noticed  under  the  right  costal  margin.  There 
was  well-marked  tenderness  and  constant  pain,  though  there  had 
been  no  severe  spasmodic  attacks. 

Operation. — 25/11/1903.  The  gall-bladder  was  found  distended 
to  the  size  of  a  goose's  egg}  the  walls  being  inflamed  and  thick- 
ened. On  incising  it,  a  quantity  of  muco-pus  escaped,  and  two 
gall  stones  the  size  of  a  small  walnut  were  removed  from  the 
cystic  duct.     The  gall-bladder  was  drained. 

After-History.— The  patient  made  a  good  recovery. 

Compression  of  Cystic  Duct  by  Hydatid  Tumour  of  Liver  :  Drainage. 

Case  537. — Mr.  V.,  aged  thirty-nine,  seen  with  Dr.  Styan, 
Ramsgate.     He  had  complained  of  pain  over  the  gall-bladder  for 


472   DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

several  years,  though  there  had  been  no  severe  paroxysmal 
attacks.  A  tumour  had  been  recently  noticed  under  the  right 
costal  margin.  The  swelling  was  tender  to  pressure,  and  was 
situated  a  little  internal  to  the  usual  position  for  a  gall-bladder. 

Operation. — 26/11/1093.  On  opening  the  abdomen,  the  gall- 
bladder was  found  thickened  and  distended,  the  cystic  duct  being 
compressed  by  a  tumour  projecting  from  the  under  surface  of 
the  left  lobe  of  the  liver,  which  on  incision  was  found  to  contain 
about  half  a  pint  of  pus,  small  hydatid  cysts,  and  debris  of  larger 
ones.  This  was  thoroughly  emptied  and  cleansed,  but  as  bile 
began  to  flow  freely  a  drainage-tube  was  inserted.  As  there 
appeared  to  be  no  other  obstruction  of  the  bile-ducts,  the  gall- 
bladder was  not  drained. 

After-History .— Good  recovery. 

Obstructed  Common  Bile-duct,  Interstitial  Pancreatitis  : 
Clwlecy stent  erostomy. 

Case  538. :;: — F.  B.,  aged  fifty-nine,  sequence  of  Case  468.  He 
recovered  from  the  operation  of  cholecystotomy  and  improved 
very  markedly,  gaining  flesh  and  strength,  but  whenever  the 
fistula  closed  he  became  jaundiced  and  had  symptoms  of  infective 
cholangitis  in  the  shape  of  ague-like  attacks,  and  after  each  attack 
he  lost  rapidly  in  weight  and  strength.  He  was  very  desirous, 
therefore,  to  have  a  further  operation  done. 

Operation. — 6/7/1903.  The  gall-bladder  'was  detached  from 
adhesions  and  made  to  communicate  by  means  of  a  Murphy's 
button  with  the  intestine.  He  took  the  anaesthetic  badly,  and 
had  a  curious  attack,  with  twitching  of  the  limbs,  which  was 
probably  dependent  on  apoplexy,  for  his  breathing  became 
altered  and  his  pulse  slow  and  feeble.  Oxygen  was  given  for  ten 
hours,  but  he  never  rallied.  In  consequence  of  his  serious  condi- 
tion during  anaesthesia  the  ducts  could  not  be  thoroughly  explored, 
though  a  swelling  could  be  felt  beneath  a  mass  of  adherent 
viscera.  At  the  autopsy  a  gall-stone  was  found  in  the  common 
duct,  and  a  microscopic  examination  of  the  pancreas  by  Dr. 
Cammidge  showed  a  small-celled  infiltration  between  the  lobules 
of  the  pancreas. 

Perigastritis  following  Cholelithiasis,  suspected  recurrence  of  Gall- 
stones :  Gastrolysis. 

Case  539." — Mrs.  M.  Z.,  aged  thirty-six,  '  spasms'  for  twenty 
years.    Cholecystotomy  in  Durban,  Natal,  ten  months  ago.    Four 

*  Cases  538  and  539  should  be  on  pages  461  and  357  respectively.  The 
omission  not  being  discovered  until  too  late  to  give  it  the  proper  order  among 
the  cases. 


APPENDIX  473 

gall-stones  removed.  After  healing  of  wound,  in  five  weeks  return 
of  pain.  Pain  always  after  food,  and  at  times  vomiting  ;  never 
vomited  blood.  Losing  flesh  rapidly.  Dilatation  of  the  stomach. 
No  tenderness  over  gall-bladder. 

Operation. —  6/7/1897.  Adhesions  between  pylorus  and  gall- 
bladder and  liver  broken  down,  and  omentum  interposed.  Bile 
ducts  explored,  no  gall-stones  found. 

Aftev-History. — July  6,  1898,  patient  writes  :  '  I  now  feel  a 
different  person  and  enjoy  perfect  health.'  1902,  quite  well. 
Normal  weight  regained. 


LIST  OF  AUTHORITIES  QUOTED 


Armenis,  1 13 

Dalton,  50 

Ami  son,  200,  314 

Dastre,  20 

Ashby,  199 

Davies,  216 

De  Burgh  Birch,  23,  8 

[ 

Baldwin,  17 

Deetz,  181 

Barbacci,  84 

Delageniere,  274,  304 

Barnard,  142,  146,  154 

Dixon,  51 

Battle,  54 

Dominici,  219 

Baudouin,  235 

Donald,  13 

Beadles,  183 

Douglas,  140 

Beaunis,  19 

Dufort,  154 

Beck,  236 

Duncan,  235 

Bennett,  201 

Durand-Fardel,  205 

Berg,  297 

Bernheim,  217 

Ehret  and  Stolz,  82 

Bertignon,  266,  267 

Elliott,  290 

Bertrand,  182 

Erdman,  123,  126 

Birch-Hirschfeld,  69 

Escherich,  83 

Bishop,  Stanmore,  193 

Eve,  153 

Bloch,  82,  273,  274 

Bonnecken,  83 

Fagge,  58 

Bouchard,  19,  83 

Fenger,  97,  278,  279,  2 

89,  294 

Bouisson,  71 

Fenwick,  Clennell,  76 

Bowman,  172 

Fenwick,  Soltau,  267 

Brault,  181 

Flexner,  84 

Bret,  181 

Ford,  72 

Brewer,  4 

Fournier,  219 

Brockbank,  135,  142,  2 

'5, 

221, 

222, 

Freund  and  Hollandei 

,  234 

239,  287 

Brodowski,  182 

Galippe,  82,  219 

Brunton,  Lauder,  238 

Gaston,  305 

Hunger,  10 

Germain  Sde,  267 
Gilbert,  219 

Cauchois,  50 

Gilbert  and  Dominici, 

84 

(  harcot,  97,  227 

Gilbert  and  Girode,  81 

,  83,  S4 

Charcot  and  Gombault 

>  7- 

!   8-> 

85 

Goodhart,  241 

Chiari,  84 

Gutteridge,  136 

Clutton,  155 

Coats  and  Finlayson,  2 

07 

210 

Hall,  Arthur,  58 

Courvoisier,    48,    50, 

86, 

89, 

97, 

Hall,  Havilland,  208 

]  40,  153,  154,   182,  2 

76, 

279, 

281, 

1  lal stead,  211,  290 

288,  304 

Hamel,  234 

Courvoisier  and  Naunyn, 

132 

Hanot,  205 

Cufifer,  7 1 

H  arley,  242,  305 

Gushing,  Harvey,  220 

[  4 

Hofmann,  48 

74] 

LIST  OF  AUTHORITIES  QUOTED 


473 


Holt,  69 
Hotchkiss,  95 

Hutchinson,  junior,  Jonathan,   76, 
103,  171 

Israel,  151 

Jaccoud  and  Aubert,  105 
Janeway,  48 
Jayle,  182 
JeafTreson,  139 
Jones  and  Clinch,  105 

Karewski,  144 

Keen,  273 

Kehr,  50,  275,  289,  294,  304 

Kennan,  126 

Kermisson  and  Rochard,  1 54 

Kilgour,  48 

Kinneir,  149 

Kishkin,  241 

Kocher,  263,  295 

Komitsky,  140 

Kummell,  288 

Kuster,  273,  289 

Lane,  90 
Lange,  273 
Langenbach,  272,  288 
Lauenstein,  289 
Leichtenstern,  142,  154 
Leser,  234 
Letulle,  12 
Littlewood,  211 
Lobstein,  153,  154 
Lund, 149 

McBurney,  295 

McGavin,  171 

Maclagan,  155 

McNeal,  205 

Martel,  50 

Martha,  83 

Martig,  276,  277,  294,  30^ 

Martin,  51 

Martin,  C,  151 

Mayo,  W.  J.,   211,  275,   300,   303, 

304 
Mayo,  W.  J.  and  C  H.,  295 
Meredith,  273 
Mertens,  103 
Mignot,  219 
Morison,  Rutherford,   14,  263,  272, 

291 
Morton,  122 
Moxon,  59 
Moynihan,  191 


Murchison,  58,  139,  227 
Murchison  and  Hale  White,  84 
Murphy,  245,  272,  305,  313 
Musser,  180,  182,  183,  192,  201 

Nattan  Lorrier,  12 
Naunyn,  57,  81,  83,  183,  224 
Netter,  81-83 
Nussbaum,  305 

Ochsner,  231 

Oddi,  11,  20 

Ogilvie,  58,  104 

Ogston,  48 

Ord,  227 

Osier,  97,  142,  228,  264 

Page,  109,  172,  291 

Palin,  151 

Parker,  G.,  68 

Paul,  117 

Peck,  58 

Pilcher,  13 

Potain,  90 

Powell,  75 

PreYost  and  Binet,  22,  29 

Oue'nu,  10 

Rendu,  205 

Reymond,  169 

Richter,  215 

Riedel,  61,  179,  289,  314 

Robinson,  Byron,  64 

Rolleston,  68,  180,  192,  201,  205 

Rolleston  and  Pigg,  60 

Roper,  164 

Ross,  72 

Roth,  137 

Russell,  198 

Rutherford,  22 

Salmuth,  48 

Sargent,  155 

Schroeder,  183,  215,  221 

Schuller,  153,  154 

Schuppel  and  Bosbrom,  118 

Seiftert,  141 

Sendler,  150 

Sheild,  91,  120 

Siegert,  182,  184 

Smith,  Greig,  276,  291 

Sprengel,  314 

Still,  221 

Stokes,  205 

Swain,  198 

Swaine,  314 


476    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


Tait,  Lawson,  276,  285 

Taylor,  Everley,  149 

Teale,  287 

Terrier,  48,  55,  83,    107,    196,   289, 

294,  301,  304,  314 
Terrier  and  Auvray,  50 
Terrier  and  Dalby,  273 
Thiersch,  1 18 
Thomson,  John,  68,  71,  72 
Thornton,  Knowsley,  172,  272,  287 
Thudichum,  62,  222 
Treves,  71,  153,  155,  156 


Virchow,  139 
Von  Wittich,  27 


Walton,  50 
Ward,  160 

Welsh  and  Blackstein,  84 
Westphalen,  27 
Whipple,  54 
Wilkinson,  151 
Wilks  and  Moxon,  201 
Willard,  120 
Williams,  Monier,  120 
Winiwarter,  305 
Wright,  266 
Wyeth,  1 16 
Wyss,  10 

Zeller,  296 
Zenker,  179,  182 


INDEX 


Abnormalities   of  gall-bladder  and 
bile-ducts,  5 
of  liver,  15 
Absence   of  cirrhosis  of  liver  in  ob- 
struction    of     bile -ducts     in 
adults,  72 
of  gall-bladder,  5,  18 
of  true  casts  of  gall-bladder  in 
croupous  inflammation,  76 
Actinomycosis  of  gall-bladder,  173 
Action  of  B.  coli  communis,  83 
Action  of  bile  on  fat,  25 
Acute  catarrhal  cholangitis,  57 
cholecystitis,  92-94 
gangrenous  pancreatitis,  126 
phlegmonous  cholecystitis,  89-91 
Adhesions   accompanying    ulceration 
of  the  gall-bladder  and  bile-ducts, 
109 
After  results  of  cholelithotrity,  286 
treatment  of  gall-bladder  opera- 
tions, 261 
Ampulla  of  Vater,  cancer  of,  205 
Analysis  of  bile,  Fairley's,  17,  23,  30 

of  gall-bladder  fluid,  33 
Anatomical  considerations,  1 
Antiseptic  action  of  bile,  24,  81 
Aperient  action  of  bile,  26 
Ascarides    as    a    cause    of    infective 

cholangitis,  103 
Aspiration  for  extravasated  bile,  50 
Association   of    cancer   of    the   gall- 
bladder with   gall-stones,  182, 

183 
of    gall-stones   with    catarrh    of 
bile-ducts,  60 
with  primary  cancer  of  bile- 
ducts,  202 

Bacillus  coli  communis,  83,  84 

in  gall-stones,  217-219 
Bifid  gall-bladder,  13 

gall-bladder  in  sheep,  13 


Bile: 

action  on  fat  of,  25 

amount  of  variation  in   flow  of, 

over  a  period,  32 
antiseptic  action  of,  24 
antiseptic  properties  of,  81 
aperient  action  of,  25 
aspiration  for  extravasated,  50 
conclusions    regarding    function 

of,  29 
constant  excretion  of,  18 
daily  quantity  of,  25 
diastatic  action  of,  23 
diurnal  variation  in  flow  of,  26 
effects  of  drugs  on  flow  of,  27 
Fairley's  analysis  of,  17,  23,  30 
method  of  collecting,  22 
observations  on  secretion  of,  21 
sterility  of  normal,  81 
tables  of  daily  excretion  of,  34 
Bile-ducts  : 

association    of    gall-stones    with 

catarrh  of,  60 
association    of    gall-stones   with 

primary  cancer  of,  202 
biliary   cirrhosis    in    connection 

with  congenital  obliteration  of, 

71 

cancer  of,  201 

capacity  of,  57 

congenital  obliteration  of,  68 

cystic  tumours  of,  195 

division  of  malignant  tumours  of, 
201 

gunshot  wounds  of,  48 

hypothesis  for  congenital  oblitera- 
tion of,  73 

in  adults,  absence  of  cirrhosis  of 
liver  in  obstruction  of,  72 

influence  of  age  on  primary 
growths  of,  202 

influence  of  sex  on  congenital 
obliteration  of,  71 

477  ] 


478    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


Bile-ducts : 

injuries  to,  48 

kinking  of,  140 

perforation  of,  130 

primary   malignant    disease    of, 

201 
secondary  carcinoma  of,  202 
situation  of  tumour  in   primary 

growths  of,  202 
solid  tumours  of,  200 
stricture  of,  115 

suppurative  inflammation  of,  80 
tumours  of,  195-200 
Biliary  casts  as  nucleus  of  gall-stones, 
62 
cirrhosis  in  connection  with  con- 
genital obliteration  of,  71 
fistula,  22 

passages,  operations  on,  262-268 
Bloch's   modification   of    cholecysto- 

tomy,  273 
Blood-supply  of  gall-bladder,  6 
Bullet  wound  of  gall-bladder,  laparo- 
tomy for,  50 

Calcified  gall-bladder,  168 

Calcium  chloride  in  haemorrhage,  use 

of,  266 
Calculi  in  common  duct,  278-282 

in  hepatic  duct,  293 
Cancer  in  association  with  ulceration 
of  gall-bladder  and  bile-ducts, 
in 
of  ampulla  of  Vater,  205 
of  bile-ducts,  201 
of  gall-bladder,  180 

associated    with   gall-stones, 

183 
associated    with   cancer    of 
the  liver,  187 
of  the  liver,  influence  of  sex  on, 

183 
Capacity  of  bile-ducts,  57 

of  gall-bladder,  1 
Carcinoma  of  bile-ducts,  secondary, 
202 
of  gall-bladder,  primary,  191 
Cases  illustrating : 

acute  phlegmonous  cholecystitis, 

adhesions  causing  ulceration    of 
the  gall-bladder  and  bile-ducts, 
109 
biliary  fistula,  22 
calcified  gall-bladder,  168 
calculi  in  the  common  duct,  280 
cancer  of  the  gall-bladder  asso- 
ciated with  cancer  of  the  liver, 
187 
catarrhal  jaundice,  60 
cholecystectomy,  299 
cholecystenterostomy,  311 


Cases  illustrating  : 

cholecystenterostomy,    for    con- 
tracted gall-bladder,  255 
cholecystotomy,  254 

with    subsequent   treatment 
by  injections   of  olive  oil, 
282 
choledochenterostomy,  315 
choledochostomy,  315 
choledochotomy,  292 

for  gall-stones  firmly  packed 
in  cystic  duct,  256 
cholelithotrity,  286 
contracted  gall-bladder,  67,  254 
croupous  inflammation,  79 
cystic  tumours  of  bile-ducts,  197 
distension  of  gall-bladder  due  to 

different  conditions,  169 
duodeno-choledochotomy,  296 
gall-stones   associated   with    en- 
largement of  pancreas,  260 
gall-stones  associated  with  pyloric 

stenosis,  259 
gall-stones    in  a   dilated    cystic 

duct,  282 
gall-stones     pressed     into     duo- 
denum, 282 
hydatid  cyst  of  gall-bladder,  171 
infective  cholangitis,  99 
intervisceral  fistula,  258 
intestinal  obstruction  due  to  ad- 
hesions, 159 
due  to  gall-stones,  145-149 
due  to  local  peritonitis,  163 
due  to  volvulus,  158 
removal  of  calculi  from  hepatic 

duct,  293 
removal  of    primary  growth   of 

bile-ducts,  211 
rupture  of  hepatic  duct,  53 
stricture  of  common  duct,  115 

of  cystic  duct,  114 
suppurative  cholangitis,  101 
thickened  and    ulcerated    bowel 
due  to  a  gall-stone,  160 
Catarrh    of  bile-ducts,  association  of 
gall-stones  with,  60 
of  bile-ducts,  jaundice  associated 

with,  59 
of  gall-bladder  and  bile-ducts,  56 
lithiatic,  62 
Catarrhal  cholecystitis,  62 

cholecystotomy  for  relief  of,  63 
cholangitis,  acute,  57 
inflammation,     jaundice    depen- 
dent on,  61 
jaundice,  57-62 
Cause  of  acute  cholecystitis,  92 
Causes  of  catarrhal  jaundice,  58 
of  empyema,  85 

of  hydrops  and   dropsy  of  gall- 
bladder, 168 


INDEX 


479 


Causes  of  infective  cholangitis,  98 
of  suppurative  cholangitis,    ico, 

102 
of  ulcers  of  the  gall-bladder  and 
bile-ducts,  108 
Cholangitis,  59 

acute  catarrhal,  57 

ascarides  as  a  cause  of  infective, 

103 
chronic,  59 

complications  of  infective,  98 
hydatid    disease   as    a  cause   of 

infective,  102 
infective,  97 
influenza  as  a  cause  of  infective, 

105 

leading  to  suppurative  lymph- 
angitis, 60 

malignant  disease  as  a  cause  of 
infective,  104 

suppurative,  100 

therapeutic  results  following 
operations  for  suppurative, 
107 

tubercular,  108 

typhoid  fever  as  a  cause  of  infec- 
tive, 104 
Cholecystectomy,  298 

by  cautery,  Mayo's  case  of,  300 

for  benign  neoplasms,  301 

for  gangrene  of  the  gall-bladder, 

303 
for   malignant    disease   of    gall- 
bladder, 299 
for  persistent  fistula,  302 
for   removal   of  calcareous  gall- 
bladder, 301 
for  simple  empyema,  89 
for  wound  of  gall-bladder,  51 
indications  for,  298 
Mayo's    method   of  performing, 
301 
Cholecystenterostomy,  305 

author's  indications  for  perform- 
ance of,  306 
contra-indications    for    per- 
formance of,  306 
description  of  operation  of,  307 
history  of,  305 
in  the  case  of  a  feeble   patient, 

283 
Murphy's     indications     for    the 
performance  of,  305 
contra-indications     for    per- 
formance of,  306 
Cholecystitis,  acute  phlegmonous,  89 
and  cholangitis,  obliterative,  66 
catarrhal,  62 

danger  of  phlegmonous,  80 
deformities  of  gall-bladder  in  ob- 
literative, 66 
obliterans,  5 


Cholecystotomy,  270 
it  deux  temps,  82 
Bloch's  modification  of,  273 
Delageniere's  method  of,  273 
for  relief  of  catarrhal   cholecys- 
titis, 63 
indications  for,  270 
modifications  of,  272 
Choledochenterostomy,  284,  315 
Choledochostomy,  284,  314 
Choledochotomy,  284,  288 

description      of      operation     of, 

289 
drainage  in,  291 
history  of  operation  of,  288 
retroduodenal,  297 
Cholelithiasis       following        typhoid 
fever,    Harvey    Cushing's    conclu- 
sions from  cases  of,  220 
Cholelithotrity,  261,  285 
Cholesterin,  216,  217 
Chronic  catarrh,  association  of  cancer 
of  liver  or  bile-ducts  with, 
60 
medical  treatment  of,  62 
of  gall-bladder,  62 
Classes  of  intestinal  obstruction  due 

to  gall-stones,  143 
Collapse  as  a  symptom  of  gall-stones, 

226 
Colour  of  gall-stones,  216 
Common  and  pancreatic  ducts,  varia- 
tions of  terminations  of,  12 
Common  duct : 

complete  laceration  of,  54 
divisions  of,  8 
intraparietal  portion  of,  11 
pancreatic  portion  of,  9 
retroduodenal  portion  of,  9 
situation  of,  8 

supraduodenal  portion  of,  9 
Complications  of  gall  stones,  228 

of  infective  cholangitis,  98 
Composition  of  gall-stones,  19,  216 

of  walls  of  gall-bladder,  3 
Conclusions    regarding    function    of 

bile,  29 
Congenital     malformation     of    gall- 
bladder, 12 
obliteration  of  bile  ducts,  6S 

biliary   cirrhosis  in  connec- 
tion with,  71 
hypothesis  for,  j^ 
influence  of  sex  on,  71 
is     primarily    a     congenital 
cirrhosis,      considerations 
in  favour  that,  74 
Considerations,  physiological,  iS 
Consistency  of  gall-stones,  216 
Contracted  gall-bladder,  67,  255 
Croupous     inflammation      of      gall- 
bladder and  bile-ducts,  73 


48o    DISEASES  OF  THE  GALL-BLADDER  AND  BILE -DUCTS 


Croupous   inflammation,  absence   of 
true      casts      of     gall  - 
bladder  in,  76 
formation  of  membrane  as 
a  cause  of,  76 
Cystic  duct,  situation  of,  6 

tumours  of  bile-ducts,  195 
Cyst   of    liver    caused    by    ruptured 
hepatic  duct,  54 
of  liver,  mucous,  20 


Dastre's  experiments  on  dogs,  20 
Deformities  of  gall-bladder  in  oblitera- 

tive  cholecystitis,  66 
Delageniere's    method    of    cholecys- 

totomy,  274 
Description  of  operations,  249 

of    operation  of    cholecystenter- 
ostomy,  307 
of  choledochotomy,  289 
of  cholelithotrity,  285 
of  duodeno-choledochotomy, 

295 
Diagnosis    between    gall-stones    and 
acute  pancreatitis,  233 
and  angina  pectoris,  234 
and  appendicitis,  230 
and  chronic  pancreatitis,  233 
and  malignant  disease,  233 
and    pyloric    and    duodenal 

ulcer,  232 
and  pyloric  stenosis,  232 
and  right  renal  colic,  232 
and  spinal  neuralgia,  233 
of  acute  cholecystitis,  93 
of  cancer  of  the  gall-bladder,  184 
of  croupous  inflammation,  79 
of  gall-stones,  230 
of    primary     growths     of    gall- 
bladder, 310 
of  tumours  of  gall-bladder,  177 
Diagnostic  operations,  244 
Diastatic  action  of  bile,  23 

ferment,  23 
Diet  in  biliary  fistula,  25 
Dilated  gall-bladder,  5 
Disadvantages  of  cholelithotrity,  285 
Distension  of  gall-bladder,  167 

due  to  calcified  gall-bladder, 

168 
due  to  different  conditions, 

cases  illustrative  of,  169 
due  to  empyema,  169 
due  to  hydatid  cyst,  171 
due  to  hypertrophy,  169 
due  to  lipoma,  170 
from  bile,  167 
from  concretions,  167 
Diurnal  variation  in  flow  of  bile,  26 
Divisions  of  common  duct,  8 
of  gall-bladder,  1 


Divisions  of  inflammatory  affections 
of  gall-bladder  and  bile-ducts, 

56 
of    malignant   tumours    of    bile- 
ducts,  201 
Drainage  in  choledochotomy,  291 
in  empyema,  89 
in  gall-bladder  operations,  268 
in  rupture  of  gall-bladder,  51 
Duct,  complete  laceration  of  common, 

54 
divisions  of  common,  9 
intraparietal  portion  of  common, 

11 
pancreatic  portion  of  common,  9 
retroduodenal  portion  of  common, 

9 
supraduodenal  portion   of  com- 
mon, 9 
Duodeno-choledochotomy,  284,  295 

Effects  of  drugs  on  bile  flow,  27 
on  typhoid  bacilli,  84 

Empyema  of  gall-bladder,  85 

causing  distension,  169 

Etiology  of  catarrhal  jaundice,  57 

Example  of  cholecystotomy,  253 

Excretion  of  bile,  18 

in  cats,  Beaunis  on  the,  19 
tables  of  daily,  134 

Extravasated  bile,  aspiration  for,  50 


Fairley's  analysis  of  flow  of  bile,  17, 

23.  3° 
Fistula,  biliary,  135 

biliary  cutaneous,  134 
intervisceral,  258 
of    gall-bladder   and   bile-ducts, 
132 
not  biliary,  23 
post-operative,  134 
treatment  of  biliary,  135 
Fistulae,  biliary  gastric,  139 
gall-bladder  colic,  138 
mucous,  134 

pathological  surface,  136 
Flow  of  bile  over  a  period,  amount  ot 

variation  of,  32 
Formation  of  a  tumour  as  a  symptom 

of  gall-stones,  226 
Frequency  of  calculi  in  the  common 
duct,  278 
of  fistula  of  the  gall-bladder  and 

bile-ducts,  133 
of  gall-stones  in  different  cities, 

215 
of  jaundice  in  typhoid  fever,  58 
of  stricture  of   the    gall-bladder 
and  bile-ducts,  133 
Fundus    of    gall-bladder,    relations 
of,  1 


INDEX 


481 


Gall-bladder  : 

absence  of,  518 
actinomycosis  of,  173 
aspects  of  body  of,  2 
bind,  13 

bifid,  in  sheep,  13 
Mood-supply  of,  6 
cancer  of,  180 
capacity  of,  1 

cholecystectomy  for  wound  of,  51 
chronic  catarrh  of,  62 
composition  of,  19 
composition  of  walls  of,  3 
congenital  malformations  of,  12 
contracted,  management  of,  254 
diagnosis  of  cancer  of,  184 
diagnosis  of  tumours  of,  177 
dilated,  5 

distension  of,  167-171 
divisions  of,  1 
drainage  for  rupture  of,  51 
existence  of  typhoid  bacilli  in,  85 
fluid,  analysis  of,  33 
gangrene  of,  95 
hour-glass,  13 

hydrops  and  dropsy  of  the,  168 
in    obliterative  cholecystitis,  de- 
formities of,  66 
laparotomy  for  bullet  wound  of, 

5° 
mucous  membrane  of,  4 
operations,  after-treatment  of,  361 
rarity  of  gangrene  of,  195 
relations  of,  1 

of  fundus  of,  1 
of  lower  surface  of,  2 
of  neck  of,  3 
of  peritoneum  to,  4 
of  superior  surface  of,  2 
rupture  of,  due  to  traction,  48 
sarcoma  of,  192 
simple  growth  of,  192 
suture  of  small  wound  of,  50 
tumours  of,  174-179 
Gall-bladder  and  bile-ducts  : 
abnormalities  of,  5 
adhesions  causing  ulceration  of, 

109 
cancer  in  association  with  ulcera- 
tion of,  III 
catarrh  of,  56 
causes  of  ulcers  of,  108 
croupous  inflammation  of,  75 
divisions  of  inflammatory  affec- 
tions of,  56 
Erdman's    cases   of    perforation 

of,  123 
fistula  of,  131 

frequency  of  fistula  of,  133 
frequency  of  stricture,  112 
general  considerations  bearing  on 
operations  on,  245 


Gall-bladder  and  bile-ducts  : 

haemorrhage  in  association  with 
ulceration  of,  in 

inflammatory  affections  of,  56 

perforation  of,  119 

peritonitis  associated  with  ulcera- 
tion of,  no 

stricture  of,  112 

tumours  of,  166 

ulceration  of,  108 

varieties  of  fistula  of,  132 
Gall-stones  : 

bacilli  in,  217-219 

biliary  casts  as  nucleus  of,  62 

I  irockbank's  experiments  on,  240 

collapse  as  a  symptom  of,  226 

colour  of,  216 

complications  of,  228 

composition  of,  216 

consistency  of,  216 

diagnosis  of,  230 

formation    of    a    tumour    as    a 
symptom  of,  226 

indications  for  operating  for,  243 

influence  of  age  on,  221 
of  diet  on,  222 
of  habits  on,  222 
of  sex  on,  221 

jaundice  as  a  symptom  of,  227 

medical  treatment  of,  243 

paroxysmal  pain  as  a  symptom 
of,  224 

pathology  and  etiology  of,  215 

removal  of  largest,  215 

Rontgen  rays  as  an  aid  to  diag- 
nosis of,  236 

shape  of,  216 

surgical  treatment  of,  243 

vomiting  as  a  symptom  of,  226 
Gall-stones    and    acute   pancreatitis, 
diagnosis  between,  233 

and    angina    pectoris,    diagnosis 
between,  234 

and   appendicitis,    diagnosis   be- 
tween, 230 

and  catarrh  of  bile-ducts,  60 

and   chronic    pancreatitis,    diag- 
nosis between,  232 

and  enlargement  of  pancreas,  26 

and  malignant  disease,  diagnosi 
between,  233 

and  pyloric  or  duodenal  ulcers, 
diagnosis  between,  232 

and  pyloric  stenosis,  259 

and   pyloric    stenosis,    diagnosis 
between,  232 

and  right  renal  colic,  diagnosis 
between,  232 

and   spinal    neuralgia,  diagnosis 
between,  233 

in  different  cities,  frequency  of, 

215 

31 


482    DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 


Gall-stones  in  the  motions,  226 

or  cholelithiasis,  215 
Gangrene  of  gall-bladder,  95,  96 

cholecystectomy  for,  303 
Gelatin  for  haemorrhage,  use  of,  267 
Gouty  diathesis,  19 
Gunshot  wounds  of  bile-ducts,  48 

Haemorrhage    associated    with    gall- 
stones, 264 
associated  with  ulceration  of  the 
gall-bladder  and  bile-ducts,  in 
use  of  calcium  chloride  for,  266 
use  of  gelatin  for,  267 
use  of  suprarenal  extract  for,  2C7 
Hepatic  duct,  situation  of,  6 
Hepatodochotomy,  297 
Hour-glass  gall-bladder,  13 
Hydatid   cyst  causing  distension    of 
gall-bladder.  169 
of  gall-bladder,  171 
disease  as   a  cause   of   infective 
cholangitis,  102 
Hydrops    and    dropsy    of    the    gall- 
bladder, 168 
Hypertrophy   causing    distension    of 
gall-bladder,  169 

Importance   of   cancer   of    the   gall- 
bladder  associated  with   gall- 
stones, 180 
of  clearing  common  duct  of  con- 
cretions, 289 
Indications  for  cholecystectomy,  298 
for  cholecystotomy,  270 
for  operating  for  gall-stones,  243 
for    the    performance   of    chole- 
cystenterostomy,  257 
Infective  cholangitis,  97 

ascarides  as  a  cause  of,  103 
hydatid  disease  as  a  cause  of, 

102 
influenza  as  a  cause  of,  104 
malignant  disease  as  a  cause 

of,  104 
typhoid  fever  as  a  cause  of, 
104 
Influence  of  age  on  gall-stones,  221 
on  intestinal  obstruction  due 

to  gallstones,  133 
on  primary  cancer   of  bile- 
ducts,  202 
of  biliary  fistula  in  digestion  and 

nutrition,  23 
of  diet  on  ^'all-stones,  222 
<>l  habits  on  gall-stones,  222 
of  sex  on  cancer  of  the  liver,  [83 
on  congenital  obliteration  of 

bile-ducts,  71 
on  ^'all-stones,  221 
on  intestinal  obstruction  due 
to  gall-stones,  153 


Influenza    as    a   cause    of    infective 

cholangitis,  105 
Injuries  to  the  bile  passages,  48 
Intervisceral   fistula  associated  with 

gall-stones,  treatment  of,  258 
Intestinal  obstruction,  142 
due  to  adhesions,  157 
due  to  gall-stones,  142 

influence  of  age  on,  153 
influence  of  sex  on,  153 
in  gall-bladder  region,   1G2, 

163 
rarity  of,  142 
site  of,  154 
due     to    passage    of    gall-stone 

through  intestine,  143 
due  to  volvulus,  157-159 
Intraparietal  portion  of  common  duct, 
11 

Jaundice   as    an    accompaniment   of 
catarrh  of  the  bile-ducts,  59 

as    an    accompaniment   of    gall- 
stones in  the  common  duct,  280 

as  a  symptom  of  gall-stones,  227 

cases  of  chronic  catarrhal,  60 

catarrhal,  57 

cause  of  catarrhal,  58 

dependent  on   catarrhal   inflam 
mation,  61 

etiology  of  catarrhal,  57 

in   typhoid  fever,   frequency  of, 

58 
post  -  mortem      appearances     of 

catarrhal,  59 
symptoms  of  catarrhal,  58 

Kinking  of  bile-ducts,  140 

Langenbach's     ideal      operation     of 
cholecystotomy,  272 

Laparotomy    for    bullet    wound    of 
gall-bladder,  50 

Lipoma   causing   distension  of  gall- 
bladder, 170 

Lithiatic  catarrh,  62 

Liver,  abnormalities  of,  15 
mucous  cyst  of,  20 
Riedel's  lobe  of,  20 

Lower  surface  of  gall-bladder,  rela- 
tions of,  2 

Malformations   of  gall-bladder,  con- 
genital, 12 
Malignant    disease    as    a    cause    of 
infective  cholangitis,  104 
of   bile-ducts,  primary,  201 
situation  of  tumours  in 
primary,  202 
of  gall-bladder,  cholecystec- 
tomy for,  299 


INDEX 


483 


Malignant   disease    associated    with 
gall-stones,  treatmenl  of,  257 

tumours   of    bil<-  ducts,    division 
of,  201 
Management     of     contracted     f4a.ll- 

bladder,  254 
Mayo's  method  of  cliolecystectomy, 

301 
Medical  treatment  of  chronic  catarrh, 
61 
of  gall-stones,  23S 
Methods    available    for    removal    of 
calculi  in  common  duct,  282 
of   performing   cholecystectomy, 

301 

of  suture  in    operations   on   the 
biliary  passages,  268 
Modifications  of  cholecystotomy,  272 
Mucous  cyst  of  liver,  20 
Mucous  membrane  of  gall-bladder,  4 
Mucus,  secretion  of,  5 
Multilocular   cystic   tumour  of  gall- 
bladder,   Stanmore    Bishop's   case 
of,  193 
Murphy's   indications    for    the   per- 
formance of  cholecystenteros- 
tomy,  305 
contra- indications   for    the    per- 
formance of  cholecystenteros- 
tomy,  306 

Neck  of  gall-bladder,  relations  of,  3 
Needling    concretions    through     the 
duct  walls,  283 

Obliteration  of  bile-ducts,  hypothesis 
for  congenital,  73 
of  the  larger  bile-ducts,  question- 
able  evidence   as    to    whether 
cirrhosis  is  dependent  on,  72 
Obliterative  cholecystitis  and  cholan- 
gitis, 66 
deformities        of      gall- 
bladder in,  66 
Observations    for   secretion    of    bile, 

21 
Obstruction  of  bile-ducts  in  adults, 
absence  of  cirrhosis  of  bone  in,  72 
Oddi's  experiments  on  the  relation  of 

bile  to  digestion,  20 
Operations,  diagnostic,  244 
description  of,  249 
preparations  for,  246 

Pancreatic  portion  of  common  duct, 

Pancreatitis,  case  illustrative  of  acute 

gangrenous,  126 
Paroxysmal  pain   as   a   symptom    of 

gall-stones,  224 
Pathology  and  etiology  of  gall-stones, 

215 


Perforation  <i  bile-ducts,  126-130 

of  gall  bladder,  1 19 
Peritoneum  to  gall-bladder,  relation 

of,    1 
Peritonitis  associated  with  ulceration 
of  gall-bladder  and  bile-ducts,  no 
I'll  lei;  monous  cholecystitis,  acute, 
danger  of,  80 
acute,  93 
Physiological  considerations,  18 
Poisonous  properties  of  bile,  Bouchard 

on  the,  19 
Position  of  the  patient  in  operations 

on  the  biliary  passages,  263 
Post-mortem  appearances  of  catarrhal 

jaundice,  59 
Predisposition  of  distended  gall-blad- 
der to  perforation,  121 
Preparations  for  operation,  24G 
Primary   carcinoma    of    ampulla    of 
Vater,    Havilland    Hall's  case 
of,  208 
growths  of  gall-bladder,  210 
malignant  disease  of  bile-ducts, 
201 
association  of  gall-stones 

with,  202 
influence  of  age  on,  202 
situation  of    tumour  in, 
202 
perforation  leading  to  formation 
of  second  cavity,  122 
Proportion    of    multiple    calculi    in 
common  duct,  278 

Rarity  of  intestinal  obstruction  due 

to  gall-stones,  142 
Relation  of  bile  to  digestion,  20 
Relations  of  gall-bladder,  1 

of  fundus  of  gall-bladder,  1 
of  lower  surface  of  gall-bladder,  2 
of  neck  of  gall-bladder,  3 
of  peritoneum  to  gall-bladder,  4 
of     superior     surface     of     gall- 
bladder, 2 
Retroduodenal  choledochotomy,  297 

portion  of  common  duct,  9 
Riedel's  lobe  of  liver,  17 
Rontgen  rays  as  an  aid  to  diagnosis 
of  gall-stones,  236 
in  gall-stones,  Beck's  experiments 
with,  236 
Rupture  of  gall-bladder,  drainage  for, 

5i 
due  to  traction,  48 

of  hepatic  duct,  53 

causing  cyst  of  liver,  54 
Rutherford's  experiments  on  dogs,  22 

Sarcoma  of  gall-bladder,  192 
Secondary  carcinoma  of    bile-ducts, 
202 

31—2 


484    DISEASES  OF  THE  GALL-BLADDER  AND  BILE  DUCTS 


Secondary   carcinoma  of    bile-ducts, 

symptoms  of,  203 
Secretion  of  bile,  observations  on,  21 

of  mucus,  5 
Sequences  of  perforation  of  bile-ducts, 
126 
of  stricture  of   the   gall-bladder 
and  bile-ducts,  113 
Sex,  influence  of,  on  congenital  ob- 
literation of  bile-ducts,  71 
Shape  of  gall-stones,  216 
Sheild's  cases  of  acute  phlegmonous 

cholecystitis,  91 
Simple  empyema,  S5-S7 

growth  of  gall-bladder,  192 
tumour  of   bile-duct,   case  illus- 
trating, 200 
Situation  of  calculi  in   the  common 
duct,  278 
of  common  duct,  8 
of  cystic  duct,  6 
of  hepatic  duct,  6 
of  incision  in  operations  on  the 

biliary  passages,  263 
of  intestinal  obstruction    due  to 
gall-stones,  154 
Solid  tumours  of  bile-ducts,  200 
Statistics  of  cancer  of  the  gall-bladder 
associated  with  gall-stones,  183 
of  cholecystectomy,  304 
of  cholecystenterostomy,  313 
of  cholecystotomy,  274 
of  choledochotomy,  294 
of  duodeno-choledochotomy,  295 
of  fistula  of  gall-bladder  and  bile- 
ducts,  133 
of  intestinal  obstruction  due  to 
gall-stones,  154 
Sterility  of  normal  bile,  81 
Stricture  of  bile-ducts,  114 

of  gall-bladder  and  bile-ducts,  112 
of  hepatic  duct,  116 
Superior  surface  of  gall-bladder,  rela- 
tions of,  2 
Suppurative  cholangitis,  100-107 

inflammation  of  bile  passages,  80 
lymphangitis,  chronic  cholangitis 
leading  to,  60 
Supraduodenal    portion   of    common 

duct,  9 
Suprarenal  extract  for  haemorrhage, 

use  of,  267 
Surgical  treatment  of  gall-stones,  246 
Suture  of  small  wound  of  gall-bladder, 

50 
Symptom  of  gall-stones,  collapse  as  a, 
226 
formation  of  a  tumour  as  a, 

226 
jaundice  as  a,  227 
paroxysmal  pain  as  a,  224 
vomiting  as  a,  225 


Symptoms  of  acute  cholecystitis,  92 
of  calculi  in  common  duct,  280 
of  cancer  of  gall-bladder,  184 
of  catarrhal  cholecystitis,  G4 
of  catarrhal  jaundice,  58 
of  chronic  cholangitis,  59 
of  gall-stones,  223 
of  infective  cholangitis,  97 
of  injury  to  bile-ducts,  49 
of  intestinal  obstruction   due  to 
gall-stones,  155 
due  to  volvulus,  158 
of  perforation  of  bile-ducts,  130 
of  secondary  carcinoma  of  bile- 
ducts,  203 
of  simple  empyema,  87 
of  stricture  of  bile-ducts,  115 
of  suppurative  cholangitis,  105 
of  tumours  of  gall-bladder,  174 

Tables  of  daily  excretion  of  bile,  34 
Termination   of    common    and    pan- 
creatic ducts,  variations  of,  12 
Therapeutic  results  following  opera- 
tions for   suppurative   cholangitis, 
107 
Treatment  of  acute  cholecystitis,  94 
of  biliary  fistula,  135 
of  cancer  of  gall-bladder,  185 
of  catarrhal  cholecystitis,  65 
of  catarrhal  jaundice,  62 
of  croupous  inflammation,  80 
of  empyema,  89 

of     gall-stones    associated    with 
enlargement  of  pancreas,  260 
associated  with  pyloric  steno- 
sis, 259 
in  ampulla  of  Vater,  257 
in  hepatic  ducts,  257 
of  infective  cholangitis,  ico 
of  intervisceral  fistula  associated 

with  gall-stones,  258 
of  intestinal  obstruction  due  to 

gall-stones,  155 
of    intestinal   obstruction  due   to 

volvulus,  159 
of   malignant  disease  associated 

with  gall-stones,  257 
of  perforation  of  bile-ducts,  130 
of  primary  growths  of  gall-blad- 
der, 211 
of  stricture  of  ducts,  116 
of  suppurative  cholangitis,  106 
of  tumours  of  gall-bladder,  179 
Tubercular  cholangitis,  108 
Tumours  of  bile-ducts,  195 
solid,  200 
varieties  of,  166 
of  gall-bladder  and  bile-ducts,  1C6 
of  gall-bladder,  174-179 
Typhoidal  ulceration,  perforation   of 
gall-bladder  in,  120 


INDEX 


Typhoid  bacilli,  effects  of,  84 

in  gall-bladder,  exi  itence  of, 

85 

Typhoid  fever  as  a  cause  of  infective 

cholangitis,  104 

frequency  of  jaundice  in,  58 

Ulceration  of  gall-bladder  and  bile- 
ducts,  108 
adhesions  accompanying,  109 
cancer  associated  with,  111 
causes  of,  108 

haemorrhage  associated  with,  in 
peritonitis  associated  with,  no 
variations  of,  108 

Variations  in  terminations  of  common 
and  pancreatic  ducts,  112 


Variations  in  tumours  of  gall-bladder, 

■71 
in  ulcers  of  the  gall-bladder  and 
bile-ducts,   1 
Varieties  of  cancer  of  gall-bladder, 
180 
of  fistula  of  gall-bladder  and  bile- 
ducts,  132 
of  tumour  of  bile-ducts,  166 
of  tumour  of  gall-bladder,  1 
Vomiting  as  a  symptom  of  gall-st< 
225 

Walls    of    gall-bladder,    composition 

of,  3 
Wound  of  gall-bladder,  cholecystec- 
tomy for,  51 
suture  of,  50 


THE    END 


Bailliere,   Tindall  and  Cox,  8,  Henrietta  Street,  Covcnt  Garden,  Lotnnn,   ll'.C 


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